FIRST NAME LAST NAME DATE OF BIRTH (80 years and over not accepted, ABOVE 1939) ADDRESS CITY STATE (ALL STATES) Zip Code PHONE NUMBER GENDER PRIMARY INSURANCE (MEDICARE INSURANCE) INSURANCE ID Do you have Diabetic (Type 1 or Type 2)? Do you do Diabetic Testing? If yes, then how many times in a day? Taking Insulin (Must be taking insulin 2x a day) Do you use Injectable ( like syringe or Pin or Pump or other )