Name (required)

Email (required)

Phone

Date Of Birth


Please answer the following questions:

1. Are you 45 years old or older

2. Have you had one of the following:
Prior Myocardial InfarctionPrior Stroke (ischemic or hemorrhagic stroke)Symptomatic Peripheral Arterial Disease (PAD), or peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease

If yes, please provide date of occurrence:

3. Is your BMI 27 kg/m² or greater?
yesno

4. What is your height?

5. What is your current weight?

6. Do you have any history or presence of Chronic Pancreatitis?

If yes, please provide date for must current episode:

7. Are you on dialysis?

8. Any history of malignant neoplasm within the last five years?

 

captcha

Type the code above:

 

After reviewing your answers, the study team will contact you to schedule a screening visit if you qualify. Thank you in advance for helping us advance science.