Past Medical History:
Investigation / Test Results (within last 12 months):
Please attach the following results taken within the last 12 months:
FBG (attach OGTT result if FBS >5.5, < 7.0); LIPIDS: TC, HDL, LDL, TRIGs
Data collection at Diabetes Australia
Vic is the peak consumer body and leading charity representing all people affected by diabetes and those at risk.
From time to time, opportunities will arise for people at risk of diabetes to participate in research activities.
Please tick here if you DO NOT want to participate in research or receive information about further research into the prevention of diabetes.
If you have any questions regarding the completion of this form call 1300 136 588. Please send the completed form to:
Life! Taking Action on Diabetes
570 Elizabeth Street, Melbourne 3000
Fax: 9667 1778
Diabetes Australia ABN 47 008 529 461