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Lifestyle Change Program Intake Form
Aren't you excited about the changes that are coming! Join us for the Diabetes Prevention Program.
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Email
*
Your email
First Name:
*
Your answer
Last Name:
*
Your answer
Phone Number
*
Your answer
Mailing Address (complete)
*
Your answer
Preferred Contact
*
Email
Phone
Mail
Other:
Gender
*
Female
Male
Prefer not to say
Other:
Race
*
American Indian or Alaska Native
Asian
Black
Native Hawaiian or Pacific Islander
White
More than one
Other:
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Height
*
Your answer
Weight
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Have you been told by a health care provider that you have pre-diabetes, elevated blood sugar or borderline diabetes? (check one)
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Yes
No
If yes, what type of blood test was performed? (check all that apply)
*
Finger Prick Blood Test
Fasting Glucose Test (blood test where blood was drawn with needle)
Hemoglobin A1C test
Oral Glucose Tolerance Test
Other:
Required
If you are a woman, have you ever been told by a health care provider that you had Gestational Diabetes Mellitus (GDM) during pregnancy? (check one):
*
Yes
No
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