Registration Form – Prevent Diabetes

Name (Required)

First

Last

Email (Required)

Set Your User Name (Required)

Set Your Password (Required)

Password

Confirm Password

Please enter your password in the field on the left and then confirm it. You can change it later if you wish.
If you do not enter a password, one will be generated for you.

Phone (Required)

State of residence (Required)

ZIP Code (Required)

Primary Care Physician name

Age (Required)

Height (inches) (Required)

Enter your weight in pounds

Did you take the Prediabetes Risk test? (Required)

Yes
No

Have you had a blood test in past year showing risk? (Required)

Yes
No

Which test have you had? (Required)

Fasting blood sugar
HbA1C
Plasma glucose

Have you been diagnosed with gestational diabetes during a previous pregnancy? (Required)

Yes
No
Not applicable

What is your motivation for enrolling in this program? (Required)

Health care professional
Blood test results
Prediabetes risk test (short survey)
Someone at a community-based organization (church, community center, fitness center)
Family or friends
Current or past participant in the National DPP LCP
Employer or employer’s wellness plan
Health insurance plan
Media advertisements (social media, flyer, brochure, radio ad, billboard, etc.)

Did a health care professional ask you to join? (Required)

Yes, a doctor/doctor’s office
Yes, a pharmacist
Yes, other healthcare professional
No

Ethnicity (Required)

Hispanic or Latino
NOT Hispanic or Latino
Prefer not to answer

Sex (Required)

Male
Female
Prefer not to answer

Gender (Required)

Male
Female
Transgender
Prefer not to answer

Education (Required)

Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High school graduate)
Some college or technical school
College or technical school graduate or higher
Prefer not to answer

PreventT2 Program

Prevent Type2 Registration Form

Please complete all required questions.