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Islet & Pancreas Transplant Questionnaire

Pancreas and islet transplantation are options for some patients with Type 1 diabetes mellitus. Pancreas transplantation is a clinically accepted treatment and Islet transplantation is done as a research procedure with approval from the Food and Drug Administration. To find out if you are a suitable candidate for pancreas or islet transplantation, please take a couple of minutes to answer this questionnaire. Remember that Islet transplantation is offered to people with very specific requirements and very few patients may be suitable candidates. Based on your answers, we will direct you to more evaluation for Islet transplantation or various other programs with contact information at our Institution that may be able to help you.

I understand that the assessment from this questionnaire will not be used for diagnostic purposes but may be used to is to be used to determine what services are available to me at Mayo Clinic.

1) Are you between the ages of 18 and 60? Yes
No
2) Have you had type 1 diabetes for more than 5 years? Yes
No
3) To calculate your Body Mass Index (BMI) enter height & weight.
Height: ft in
Weight: lbs.
Note: The BMI that is calculated will not be displayed.
4) What is your daily insulin usage? Less than 40 units
Between 40 - 70 units
Greater than 70 units
5) Do you currently use an insulin pump? Yes
No
6) Do you currently take 3 or more injections of Insulin daily? Yes
No
7) Are you able to recognize when your blood sugar is low? Yes
No
8) Have you ever had a severe insulin reaction? Yes
No
Severe hypoglycemia=requiring help from another person. Such reactions may make a patient unconscious or produce seizures.
9) Is your kidney function normal? Yes
No
I Don't know