DPP Participant Intake Form
Did a healthcare professional recommend that you join this program?
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, other healtchare professional
Type option 4
Email
*
example@example.com
Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Age at start of program
*
Height (to nearest whole inch)
*
Sex
*
Female
Male
Prefer not to say
Gender
*
Male
Female
Transgender
Prefer not to say
Race (may select multiple)
*
American Indian or Alaska Native
Asian or Asian American
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethincity
*
Hispanic or Latino
Not Hispanic or Latino
Prefer Not to Say
Education (Highest Level Completed)
*
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High School Graduate)
Some college or technical school
College/ technical school graduate or higher
Prefer not to say
State of Residence
*
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Motivation and Insurance
Who/What motivated you to sign up for this program? Please select the MOST influential factor out of the list below
*
Health care professional recommendation/referral to DPP
Blood test results
Prediabetes risk assessment (a short survey)
Someone at a community based organization (e.g. church, community center, fitness center)
Family or friends
Current or past participant in the National DPP program
Employer or employer's wellness plan
Health insurance plan
Media advertisements (social media, flyer, brochure, radio ad, billboard, etc)
Did a healthcare professional recommend that you join this program?
*
Yes, a doctor/doctor's office
Yes, a pharmacist
Yes, other healthcare professional
No
Who is the primary payer for your participation in this program?
*
Medicare
Medicaid
Private Insurer
Self-pay
Dual Eligible (Medicare and Medicaid)
Grant Funding
Employer
Free of charge
Other
If you selected private insurance for the previous question, what is your insurance provider?Your answer
If you selected private insurance, what is your insurance number?Your answer
If you selected Medicare for the previous question, what is your Medicare Beneficiary Identifier?Your answer
Which of the following was used to reach a diagnosis of pre-diabetes?
*
Glucose Test (fasting blood glucose or glucose tolerance test)
HbA1c Value
Previous diagnosis of GDM (gestational diabetes mellitus) during previous pregnancy
Screening / Risk Assessment for prediabetes
Most recent HbA1C Value
*
When was this HbA1C Value measured?
*
-
Month
-
Day
Year
Date
Signature
*
Clear
Submit
Should be Empty: