Your Metabolic Status

2 Minute Review

Complete this questionnaire. JJ Armstrong reviews every submission personally within 24-48 hours.

📋 Personal Information

Confidential. Used only for your audit.

First Name *

Last Name *

Email Address *

Phone Number *

🩸 Current Diabetes Status

Be honest. This determines your 3-Light classification.

Diagnosis *

Most Recent HbA1c *

Age *

💊 Current Medications

Select all that apply. This is critical for safety.

Diabetes Medications *

Metformin

Sulfonylureas (Glipizide/Glyburide)

SGLT2 (Farxiga/Jardiance)

GLP-1 (Ozempic/Mounjaro/Wegovy)

Insulin

Other / None of the above

Please specify other medications:

Include drug names and dosages if known.

If taking insulin: approximate total daily units

⚠️ Complications & Red Flags

Select all that apply. Honesty here protects your safety.

Peripheral Neuropathy (numbness/tingling in feet)

Retinopathy (eye damage)

Nephropathy (kidney damage/eGFR <45)

Foot ulcer or amputation history

Heart disease / stroke history

None of the above

🔥 Readiness Assessment

On a scale of 1-10, how committed are you to reversing your T2D in the next 3-6 months?

Readiness Score *

📝 Brief Overview

Share anything else JJ should know (optional but helpful).

Medical Disclaimer: This audit is for educational and informational purposes only. Always consult with your physician before making any changes to medications, diet, or exercise. Submission of this form does not establish a patient-provider relationship.

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