Nomination Form for GTT (Glucose Tolerance Test)
If your latest Hba1c is 6 or less (report should be from 1 June to 15 August, 2018) and you are free of ALL INSULIN and MEDICINES for atleast 2 months, you can nominate yourself for this test by filling in the details below...
Please Enter Your FIRST NAME *
Your answer
Please Enter Your LAST NAME *
Your answer
Please Enter Your MOBILE NUMBER *
Your answer
Please Enter Your EMAIL ID
Your answer
Please Enter Your CITY *
Your answer
FFD PROGRAM done and BATCH number (e.g Intensive 36, TRP 30, Basic, etc)
Your answer
Please Enter Your DESIGNATION (e.g. Housewife, Retired, Salaried, Business Owner, Teacher, etc)
Your answer
Please Enter Your AGE *
Your answer
Year of diabetes DETECTION (e.g. 2004) *
Your answer
Whether you were on INSULIN or on TABLETS or BOTH before joining FFD *
Your insulin and medicine details (Name and Dosage) before starting FFD Program
Your answer
WEIGHT just before joining FFD program
Your answer
WAIST in inches or centimeters just before joining FFD program
Your answer
You became FREE of all diabetes medications in how many days/weeks/months/ years? *
Your answer
You have been free from all diabetes medications SINCE (Mention date/month/year) *
Your answer
Latest HbA1c LEVEL (report date should be between 1 May to 15th August 2018). Please send soft copy of this test to drsmita@freedomfromdiabetes.org *
Your answer
Date of LATEST HbA1c Report *
MM
/
DD
/
YYYY
Please write your preference of CITY for doing GTT (Pune or Name of Your City - for out of Pune participants)
Your answer
Please write your preference of DATE for doing GTT (if doing it in Pune with us)
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