Instructions for completing the form: If you have an idea of what the answers to any question is, please provide your best recollection or estimate. If you have no idea what the answer to a question is, leave it blank. If you need help completing the questionnaire, do not hesitate to call your transplant center coordinator.

    If you complete the questionnaire on-line, your IPN address may be collected by the servers at the EMMES Corporation (CITR Coordinating Center), 401 North Washington Street, Suite 700, Rockville, MD 20850. EMMES has no plans to utilize this information in any way. Your birthdate is necessary to accurately link your answers to your existing data in the CITR database. You have the option of downloading a hard copy of the questionnaire, filling it out by hand and mailing it to the center that performed your transplant (address available at www.citregistry.org and click on your center on the map). Should you have any questions regarding the privacy of your imformation, you may contact us at info@citr.org or 301-251-1161

    This data will be sent to your center coordinator for verification before it is added to the database.

    1. Date of birth: (mm/dd/yyyy)

    2. Transplant Center where you received your islets:

    3. What is your average daily insulin use over the past two weeks: Total units per day

    4. What is your most recent (if you can't remember exactly when, give your best guess):
          a. HbA1c measurement: Month/Year:
          b. C-peptide measurement: Month/Year:
          c. Serum Creatinine measurement: Month/Year:

    5. In the past year, how many times did you experience an episode of hypoglycemia that required the assistance of another person to recognize or help you treat the episode (you can answer 0 for none, or 1, 2, 3, 4, etc. If you can't remember exactly how many, give your best estimate, for example, 5 or 10):
               i. How many of the above episodes involved a loss of consciousness and/or
                  seizure: (0 for none, 1, 2, 3, etc. or your best estimate)

    6. Have you received any other transplants since your last islet transplant:
          a. Islet                 Yes No    If Yes, Month/Year:
          b. Kidney           Yes No    If Yes, currently functioning? Yes No
          c. Pancreas       Yes No    If Yes, currently functioning? Yes No
          d. Liver               Yes No    If Yes, currently functioning? Yes No
          e. Heart              Yes No    If Yes, currently functioning? Yes No
           f. Lung               Yes No    If Yes, currently functioning? Yes No

    7. During the past 3 months, have you had numbness, pain. tingling or loss of feeling in your hands or feet, other than from your hands or feet falling asleep?
    Yes No

    8. List all prescription medications that you are currently taking:
          a.
          b.
          c.
          d.
          e.
          f.  

    9. Have you had any medical problems, major illnesses, or experiences and adverse effects since the last follow-up? Yes No
       If Yes, please describe each problem/event:
    EVENT
    Select one answer for each event
    Weak or failing kidneys (do not include kidney stones, bladder infections, or incontinence):
    No Y-Treated Y-Hospitalized
    Coronary heart disease:
    No Y-Treated Y-Hospitalized
    Stroke:
    No Y-Treated Y-Hospitalized
    Peripheral vascular disease:
    No Y-Treated Y-Hospitalized
    Retinopathy - Diabetes affecting your eyes or vision:
    No Y-Treated Y-Hospitalized
    Other:
    No Y-Treated Y-Hospitalized
    Other:
    No Y-Treated Y-Hospitalized
    Other:
    No Y-Treated Y-Hospitalized
    Other:
    No Y-Treated Y-Hospitalized

    10. Have you had any eye surgeries since your last visit to the transplant center?
    Yes No
          a. If Yes, indicate type of surgery:
              Month/Year:
          b. Which eye (Check one)? Right Left Both

    11. In general, would you say your health is:
              Excellent Very Good Good Fair Poor
    12. May we contact you by phone if we have any questions? Yes No
          If yes, please provide your phone number:
    Please provide any further information or any feedback regarding your participation in CITR:
    Date: