Intake Form- National Diabetes Prevention Program

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Email *

First and Last Name *

Phone Number: *

Date of Birth *

YYYY

Address (Ex. 123 Main Street Capitol Heights, MD 20747): *

Gender Assigned at Birth *

Female

Male

Prefer not to say

Gender Identity *

Female

Male

Transgender

Prefer not to say

Ethnicity: *

Hispanic or Latino

Not Hispanic or Latino

Race: *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other:

Education: *

Less than Grade 12 (No high school diploma or GED)

Grade 12 or GED (High school graduate)

College- 1 year to 3 years (Some college or technical school)

College- 4 years or more (College graduate)

No Report

Primary Payment Source (Insurance Information): *

Medicare

Medicaid

Private Insurance

Self Pay

Employer

Grant Funding

Other

Not Applicable

Required

Insurer Name and ID Number (Write N/A if not applicable) *

Enrollment Motivation (How did you hear about the program?) *

Healthcare Professional

Blood Test Results

Current or Past Participant in National DPP

Employer or Employer's Wellness Program

Family/friends

Health Insurance Plan (Medicaid MCO, Medicare, private)

Someone from a Community-Based Program (Church, Community Center, Fitness center)

Media (radio, newspaper, billboard, poster/flyer, etc., transit bus, train, shelter national media (TV, Internet ad), and social media (Twitter, Facebook, etc.), gas station TV, movie theater)

Other:

Enrollment Source (Did a Healthcare Professional Refer you?): *

Yes, a Doctor's office

Yes, a Pharmacist

Yes, Other Healthcare Professional

Height: *

Starting Weight? *

Have you been told by a health care provider that you have prediabetes, elevated blood sugar, or borderline diabetes? : *

Yes

If yes, what type of blood test was performed, and what were the values? (Check any that apply) *

Oral Glucose Tolerance Test

Hemoglobin A1C Test

Fasting Glucose Test

N/A

Required

What was the blood test value? Ex. A1C, Glucose, if Not applicable write N/A *

Are you pregnant now? *

Yes

If you are a woman, have you ever been told by a health care provider that you had Gestational Diabetes Mellitus (GDM) during pregnancy? *

Yes

N/A

Have you ever been told by a doctor, nurse, or other health professional that you have: (check any that apply) *

Diabetes

Hypertension

End Stage Renal Disease (ESRD)

None

Required

Are you deaf or do you have serious difficulty hearing? *

Yes

Are you blind or do you have serious difficulty seeing, even when wearing glasses? *

Yes

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? *

Yes

Do you have serious difficulty walking or climbing stairs? *

Yes

Do you have difficulty dressing or bathing? *

Yes

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping? *

Yes

Do you need an accommodation to attend the Diabetes Prevention Program class? *

Yes

Have you used tobacco/smoked in the past 30 days?

Yes

Clear selection

I have read and acknowledge the Participation Agreement Form *

Yes

Please print your full name as your electronic signature *

Today's Date: *

YYYY

Send me a copy of my responses.

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