Study for Type 1 DiabeticsPersonal information First name * Last name * Gender * Male Female Date of birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 ARE YOU A TYPE 1 DIABETIC ? * Yes No Smoking habits * Smoker Non-smoker Body Mass Index Imperial (pi) Metric (m) Height ' Height (inches) " Height m Height (cm) cm Weight kg Your BMI : Join us Preferred language * French English Phone * eg. 555 444-3333 Ext. Optional E-mail Postal code/Zip code * eg. H0H 0H0
