Diabetes Prevention Program Registration
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1)
Please select which workshop you would like to join
--Select--
Diabetes Prevention Program English In-person next available.
Diabetes Prevention Program English via Zoom 06/07/2023
Prevenga el T2 - Español siguiente disponible en persona.
Prevenga el T2 - Español siguiente disponible a traves de Zoom.
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2)
Full Name:
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3)
Date of Birth
--Select--
Jan
fgeb
mar
April
May
June
July
Aug
Sep
Oct
Nov
Dec
Month
--Select--
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
--Select--
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
4)
Race/Ethnicity
American Indian or Alaska Native
Asian or Asian American
Black or African American
White
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Other (please specify)
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5)
Street Address:
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6)
City, State
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7)
Zip code:
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8)
Phone Number:
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9)
Email:
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10)
How old are you?
--Select--
Less than 40 years (0 points)
40-49 (1 Point)
50-59 (2 Points)
60 Years or older (3 Points)
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11)
Are you a man or a woman?
--Select--
Man (1 point)
Woman (0 points)
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12)
If you are a woman have you ever been diagnosed with gestational diabetes?
--Select--
Yes (1 point)
No (0 points)
N/A, not a woman (0 Points)
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13)
Do you have a mother, father, sister, or brother with diabetes?
Yes(1 point)
No (0 Points)
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14)
Have you ever been diagnosed with high blood pressure?
--Select--
Yes (1 Point)
No (0 Point)
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15)
Are you physically active?
--Select--
Yes (0 Point)
No (1 Point)
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16)
Height:
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17)
Weight as of today:
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18)
Readiness Ruler
Importance: The willingness to change ~ Confidence: In one's ability to change ~ Readiness: A matter of priorities
On a Scale of 1 to 10 how important is it for you to make a change?
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19)
On a scale of 1 to 10, how confident are you that you could make a change if you wanted to?
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20)
On a scale of 1 to 10 how ready are you to make a change?
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21)
Do you have a physical or visual impairment?
Yes
No
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22)
By submitting this registration survey, you are certifying that you have read and understand the Area Agency on Aging of Dallas Client Rights and Responsibilities and Release of Information for Older Americans Act Program. Your information will be kept private and confidential and will contain no identifying information. A copy of this form will be mailed or emailed to you.
I read and understand the rights and responsibilities and release of information above
No, I do not.
Continue ONLY when finished. You will be unable to return or change your answers.