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ENROLL TODAY

EnrolllmWPAdmin2018-10-30T20:47:44+00:00

  • Please completed this short survey for blood sugar tracking. We will use it to send you text reminders to check your blood sugar. You will be able to submit your readings on a mobile web form. This way you will not need to worry about writing them down or bringing a journal for your visits. You’ll be able to view charts and graphs so that you can see your progress and have better control.

    Please complete the form to set up your LIFEMAP.
    * = required field

  • Must be at least 18 years of age.
    MM slash DD slash YYYY
  • You will receive reminders to check your blood sugar on the schedule defined in this form. In addition, you will receive 3-4 diabetes education and support care messages/week. LIFEMAP text care messages will come from phone number 53016. Message and data rates may apply according to your carrier text and data plan. You can opt out at any time by replying STOP to any message or you can get help with the LIFEMAP program by replying HELP.
  • (1 - Does not affect my well-being at all / 10 - Has very large effect on my well-being and quality of life)
    12345678910
  • (Please select all that apply)
  • (including beer, wine and spirits)

  • LIFEMAP Setup

  • Your current schedule. Please put one approximate time for each item.
  • :
  • :
  • :
  • :
  • :
  • :
  • :
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  • Now let’s set up your LIFEMAP. These are the days and times that you will receive reminders to check your blood sugar. You’re encouraged to check at these times. Once you get started, you can submit at other times but these are the target times. We can also adjust the schedule later if needed.
  • (Select 3-4 that represent your lifestyle)

  • Monday Reminder Times

  • (recommended around wakeup)
    :
  • (recommended around 2 hours after breakfast or first food)
    :
  • (recommended around 2 hours after lunch)
    :
  • (recommended around 2 hours after dinner)
    :

  • Tuesday Reminder Times

  • (recommended around wakeup)
    :
  • (recommended around 2 hours after breakfast or first food)
    :
  • (recommended around 2 hours after lunch)
    :
  • (recommended around 2 hours after dinner)
    :

  • Wednesday Reminder Times

  • (recommended around wakeup)
    :
  • (recommended around 2 hours after breakfast or first food)
    :
  • (recommended around 2 hours after lunch)
    :
  • (recommended around 2 hours after dinner)
    :

  • Thursday Reminder Times

  • (recommended around wakeup)
    :
  • (recommended around 2 hours after breakfast or first food)
    :
  • (recommended around 2 hours after lunch)
    :
  • (recommended around 2 hours after dinner)
    :

  • Friday Reminder Times

  • (recommended around wakeup)
    :
  • (recommended around 2 hours after breakfast or first food)
    :
  • (recommended around 2 hours after lunch)
    :
  • (recommended around 2 hours after dinner)
    :

  • Saturday Reminder Times

  • (recommended around wakeup)
    :
  • (recommended around 2 hours after breakfast or first food)
    :
  • (recommended around 2 hours after lunch)
    :
  • (recommended around 2 hours after dinner)
    :

  • Sunday Reminder Times

  • (recommended around wakeup)
    :
  • (recommended around 2 hours after breakfast or first food)
    :
  • (recommended around 2 hours after lunch)
    :
  • (recommended around 2 hours after dinner)
    :

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