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Interest in Prevent T2 Diabetes Classes
Leave This Blank:
First and Last Name
*
Phone Number
*
Email
Date of Birth
*
Gender
*
Male
Female
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
Medicaid
Tricare/VA insurance
Indian Health Service
Other
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.
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