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How Do I
Interest in Prevent T2 Diabetes Classes
Leave This Blank:
First and Last Name
Date of Birth
American Indian/Native American/Alaskan Native
Native Hawaiian/Pacific Islander
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.
Any previous gestational or pregnancy diabetes
Have you ever been diagnosed with diabetes?
Are you a state employee?
Which of the following categories describes your health insurance status? Check all that apply.
Insurance from your or your partner's employer
Indian Health Service
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)
Employer or employer's wellness program
Media (radio, TV, newspaper, flyer, poster, social media)
Do you have family members with diabetes?
I don't know
Have you had a Hemoglobin A1c test in the past 6 months?
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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