VIPT2DPRE intake form

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T2Diet Program

Before we get you started in the program, please support Dr Jedha’s ongoing research by completing the form below. We’ll check in with you again at the end of the program for an update on your progress and results. Thank you!

T2Diet ‘Prediabetes’ Program Intake Form

What was your most recent A1c* test result (%)? Please select.

*A1c is a test done by your doctor via a pathology lab, it is not a daily self-monitoring test at home. It is normally a percentage, eg: 7.7%.

Select your age

Select your weight in pounds or kilos

Pounds (lbs)

Kilograms (kg)

Select your current weight (kg)

Select your current weight (lbs)

Are you currently taking anti-glycemic* medications?

Yes

*Medications to help lower blood sugar

Select Medication Type*

Metformin

GLP-1 agonist

Other

*If you’re unsure, click the options to view medication brands/names.

Select your current Metformin dosage: mg per day

What type/brand* of GLP-1 agonist do you take?

semaglutide (Ozempic)

dulaglitide (Trulicity)

exenatide extended release (Bydureon bcise)

exenatide (Byetta)

liraglutide (Victoza, Saxenda)

lixisenatide (Adlyxin)

semaglutide (Rybelsus)

*Medication brand may vary dependent on location. Please choose the type if your brand is not listed.

Select your Trulicity dosage: mg per week

Select your Ozempic dosage: mg per week

What's your weekly dosage?

What's your daily dosage?

Please explain your medications

I prefer to go straight to the program

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