HFI Laboratory at Boston University
Application Form for HFI Support Group

You must be diagnosed with HFI in order to use this form.




First Name:
Last Name:
Address:
E-Mail:
Your Chosen Login Username ID (Maximum of 8 characters)
Ethnic background:

To select more than one item, hold down the apple key (Mac) or controll key (PC).
Place of birth (city, state, country, province):
Date of birth (MM/DD/YYYY):
Gender:
  1. Male
  2. Female
Have you been diagnosed by a physician?

If yes, give name and contact information below. If no, explain below.
  1. Yes
  2. No
Physician Contact and Address:

NOTE: You ARE REQUIRED to have your doctor send verification of your diagnosis to;

Dean Tolan, Ph.D.
Director, HFI Laboratory
Boston University
5 Cummington Street
Boston, MA, 02215
617-353-6340 FAX
Date of Diagnosis (MM/DD/YYYY):
How old were you when diagnosed?
How Were You Diagnosed? (click for information about these tests)
Most Common Symptoms:
Do you ever have episodes of hypoglycemia, dizziness, or fainting spells unrelated to eating sugars?
  1. Yes
  2. No
When are these episodes most prevalent?
    Overnight
    In the morning
    Lasts all day
    Other
    No pattern
Are you interested in becoming a part of our National Institute of Health sponsored research?
  1. Yes
  2. No