FreshRx Pre-Screen Application 
Thank you for your willingness to participate in this pre-screen survey for the FreshRx 'Food is Medicine' Program for those with Type 2 Diabetes who live in North Tulsa. Completing this survey does not guarantee a spot in the FreshRx program. We are currently working through a large waitlist. Enrollment for a new cohort can take up to 3 months. A staff member will review your pre-screen survey and follow up with you about your eligibility and perform the full enrollment process with you. If you complete this survey, it will be included in a research study evaluating the program. Participation in this study is voluntary and anonymous. The information provided will be combined with responses from other individuals. You may contact our program manager Erin Martin at erin@freshrxok.org if you have any questions about this research. By participating in this survey, I agree to my survey responses being part of a research study. 
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First Name *
Last Name *
 Cell Phone Number *
Home/Work Phone Number
Zip Code (currently, we are only serving residents of North Tulsa)? *
What is the name of your primary care doctor?  *
What is the name of your primary care clinic?  *
Date of Birth *
MM
/
DD
/
YYYY
Do you have Type 2 Diabetes? *
What was your latest HbA1c reading?
How did you hear about FreshRx? *
Required
Are you comfortable receiving text messages for this program? *
Do you have reliable transportation? *

Will you be able to pick up your produce every 2 weeks at the North Tulsa Health 

Department (5635 N. Martin Luther King Jr. Blvd. Tulsa, OK) between 9AM and 11AM every other Wednesday?
*
Which of these appliances do you have in your home to cook or store food? (Check one box per line) *
Yes, and it works
Yes, but it is not working
No
Refrigerator
Freezer (attached to refrigerator or stand-alone)
Microwave
Oven
Stove

Will you be able to attend your regular clinic visits every 3 months to check your 

HbA1c? 
*
We will offer 4 classes per month for cooking and nutrition. Are you willing to participate in at least 2 classes per month? Classes are available both in-person and online that you can watch on your phone, tablet, or computer. *
Are you committed to staying in communication with our team in regards to distributions and class attendance? (This is a required part of the program) *
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