Forms • Richmond County, NC • CivicEngage

First and Last Name*

Phone Number*

Email

Date of Birth *

Gender *

Race*

	African American/Black
	American Indian/Native American/Alaskan Native
	Asian

	Native Hawaiian/Pacific Islander
	Caucasian/White
	Other/Mixed

Ethnicity*

Hispanic

Non Hispanic

Weight- Example 175.5 or 180*

Height- Example 5.5 Ft or 5'2"*

BMI -If unknown, put a "0" in the answer box. Example: 23 or 23.5*

Blood Pressure- If unknown, put a "0" in the answer box. Example: 180/65*

Did you take the prediabetes risk test? If so, what was the score? If you did not, put a "0" in the answer box. *

Evidence of prediabetes in the past year. Please check one. *

	Fasting Glucose
	Hemoglobin A1c

Any previous gestational or pregnancy diabetes

Have you ever been diagnosed with diabetes?*

Yes

No

Are you a state employee? *

	Yes
	No

Refused

Which of the following categories describes your health insurance status? Check all that apply. *

	Uninsured
	Insurance from your or your partner's employer
	Individual insurance
	Medicare

Which one of the following health care facilities best describes your usual source of care?*

	Private doctor's office
	Hospital clinic or outpatient department
	Community health center

	Other kind of health care facility
	No usual source of care

Who referred you to this program or how did you hear about it? *

	Non-primary care health professional referral (pharmacist, nutritionist, etc.)
	Primary care provider
	Community based organization or community health worker
	Self (decided to come on your own)
	Family/Friends

	Employer or employer's wellness program
	Insurance company
	Media (radio, TV, newspaper, flyer, poster, social media)
	Other

Do you have family members with diabetes?*

	Yes
	No

	I don't know
	Refused

Have you had a Hemoglobin A1c test in the past 6 months? *

	Yes
	No

	Don't know
	Refused

What is the highest grade or year of school you completed? *

	Less than grade 12
	Grade 12 or GED (Highschool diploma)

	Some College or Associates degree 1-3 years
	Graduate College 4 years of college or more

* indicates required fields.