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Glycemic Index
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BLOOD GLUCOSE STUDY INTAKE

Lets get you started learning about your body’s blood glucose reaction.

Date*
MM slash DD slash YYYY
Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Age*
Job/Occupation/Position
How did you find out about the testing?*
Why did you enroll in the testing?
Did you eat anything between 10pm yesterday and now?*
- Yes
- No
Did you drink more than two beers or 6oz of alcohol 24 hours before now?*
- Yes
- No
Do you feel you understand how food and blood sugar levels interact?*
- Yes
- No
Have you ever heard of Glycemic Index?*
- Yes
- No
Have you ever heard of Insulin Resistance?*
- Yes
- No
Do you feel like you understand the relationship between blood sugar and insulin?*
- Yes
- No
Do you have any experience tracking blood sugar?*
- Yes
- No
Do you have any friends or family with diabetes?*
- Yes
- No

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Thank you for helping increase the knowledge around human metabolics.

Please feel free to ask any questions you might have to the attendant.

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