Diabetes Prevention Program Interest Survey

Diabetes Prevention Program Interest Survey

Thank you for your interest in the Diabetes Prevention Program! Please answer the following questions and a member of our team will be in contact to discuss the next steps.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Preferred contact method

Phone (call)Phone (text)Email
You must meet the following eligibility criteria to participate in the DPP program:

- 18+ years old

- Body mass index (BMI) of 25 or higher (23 or higher if Asian American)

- Not previously diagnosed with type 1 or type 2 diabetes

- Not pregnant
Please indicate whether you meet all 4 of the above eligibility criteria:

YesNo
You must meet at least 1 of the following criteria to participate in the DPP. Please check all that apply:

Hemoglobin A1C of 5.7-6.4% within the last yearFasting plasma glucose of 100-125 mg/dl within the last yearTwo-hour plasma glucose of 140-199 mg/dl within the last yearPreviously diagnosed with gestational diabetesReceived a high-risk result (score of 5 or higher) on the Prediabetes Risk Test
Please indicate which of the following timeframes would be best for conducting in-person sessions (choose all that apply):

Weekday mornings (between 9am - 12pm)Weekday afternoons (between 1pm - 3pm)Weekday evenings (after 5pm)
Will you be able to attend in-person sessions in Livingston?

YesNo
We want to make it as easy as possible for you to attend every session and are considering offering an option for childcare. If you were to participate, would you need childcare while you attended sessions?

YesNo
Please input the age(s) of the child(ren) that would need childcare:
Separate ages by commas if more than one child
How did you hear about this program?

Park County websiteFacebookInstagramThe Livingston EnterpriseFriend or familyOther
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