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Diabetes Prevention Client Enrollment Survey

Diabetes Prevention Program Client Enrollment

Welcome! Please take this enrollment form.

These programs are sponsored by the Center for Disease Control and we would like to collect some information to evaluate the effectiveness of the programs. If you wish to leave a question blank, you may. The page will refresh and warn you that a question was not completed. Simply click 'Next' again and you will be taken to the next page in the survey. All data is encrypted and stored securely.

Name *This question is required.

Last
First

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Mailing Address *This question is required.

Address
City
Zipcode

1. Did your doctor or other health care provider suggest you attend this program?

Yes	No
Yes	No

2. How old are you today? (years) This question requires a valid number format.

3. Are you_______

4. Are you of Hispanic, Latino, or Spanish origin?

5. What is your race / ethnicity?

American Indian or Alaskan Native
Asian
Black or African American

Native Hawaiian or other Pacific Islander
White

6. What is the highest grade or year of school you completed?

Some elementary, middle, or high school	High school graduate or GED	Some college or technical school	College 4 years or more
Some elementary, middle, or high school	High school graduate or GED	Some college or technical school	College 4 years or more

7. How did you hear about the program?

Primary Care Provider Office / Specialist	Non Primary Care Health Professional (e.g., pharmacist, dietician)	Community Based Organization / Health Worker	Family / Friends	An employer / employers wellness program	Insurance Company	Media (social media, TV, internet ad)	Self	Other - Write In

8. Please indicate if a healthcare provider has ever told you that you have any of the following chronic conditions:

Schizophrenia or other Psychotic Disorder
Stroke
Arthritis / Rheumatic Disease
Other Chronic Condition

9. What is your health insurance coverage?

Please enter an 'other' value for this selection.

10. What is your current weight (in pounds)? (This is a qualifier question for you to enroll in this program) *This question is required. This question requires a valid number format.

11. What is your height? (This is a qualifier question for you to enroll in this program) *This question is required.

Feet
Inches

12. Do you understand that this is a 12 month lifestyle changing program, with weekly meeting for 6 month and bi-weekly meeting for another 6 month (Funded by CDC and Nevada Business Group, the program is at no cost to you)? *This question is required.