American Diabetes Association: Survey - My Story about Diabetes

My Story about Diabetes

By sharing your experience with diabetes, you can help the American Diabetes Association educate lawmakers about why we need more research for diabetes research and prevention; affordable and accessible health care for people with diabetes; and the need to eliminate discrimination against people with diabetes.

By speaking out about your experiences, you help give a voice to the nearly 24 million Americans living with diabetes.

*1.

Question - Required - Please share with us your experience living with diabetes.

*2.

Question - Required - Do we have your permission to share your story with lawmakers/media? Yes
No

3.

Question - Not Required - What is your connection to diabetes? (check as many as apply to you)

	I have type 1 diabetes
	I have type 2 diabetes
	I have pre-diabetes
	My child has diabetes
	Another family member has diabetes
	A friend has diabetes
	I am a health care professional

4.

Please provide your contact information below so that we may follow up with you if we have additional questions.

Name:

Title	First Required	Last Required

E-mail:

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

Phone Number:

Yes, I would like to receive e-mail from American Diabetes Association

Yes, I would like to receive postal mail from American Diabetes Association

By completing this form I grant full permission to ADA to use copy, photographs, and other types of recordings of me in advertising, trade or any commercial purpose in legitimate accounts and promotions of this Web site. I waive the right to inspect versions of my image used for publication or the written copy used in connection with the images.

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My Story about Diabetes