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Intake Form- National Diabetes Prevention Program
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* Indicates required question
Email
*
Your email
First and Last Name
*
Your answer
Phone Number:
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Address (Ex. 123 Main Street Capitol Heights, MD 20747):
*
Your answer
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)
*
Your answer
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
No
Height:
*
Your answer
Starting Weight?
*
Your answer
Have you been told by a health care provider that you have prediabetes, elevated blood sugar, or borderline diabetes? :
*
Yes
No
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
*
Your answer
Are you pregnant now?
*
Yes
No
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
No
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
No
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
*
Yes
No
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
*
Yes
No
Do you have serious difficulty walking or climbing stairs?
*
Yes
No
Do you have difficulty dressing or bathing?
*
Yes
No
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
No
Do you need an accommodation to attend the Diabetes Prevention Program class?
*
Yes
No
Have you used tobacco/smoked in the past 30 days?
Yes
No
Clear selection
I have read and acknowledge the Participation Agreement Form
*
Yes
Please print your full name as your electronic signature
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
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