Diabetes Prevention Program Registration

Please select which workshop you would like to join

Full Name:

*3)Date of Birth


Hispanic/LatinoNot Hispanic/Latino
Street Address:

City, State

Zip code:

Phone Number:



12)Sex (Assigned At Birth)


14)Education (Check One)

15)What was your main motivation for signing up for this program? Who or what convinced you that you should try it? (Select one)

16)Did a healthcare provider ask you to join this National DPP LCP? (Select One)

17)Who is covering the cost for this program? (Select One)

Eligibility Criteria
Note: CDC eligibility requirements include A (BMI Requirement) AND B (Prediabetes determined by Blood test) or C Prediabetes determined by risk test)

The National Diabetes Prevention Program is designed to help people prevent or delay type 2 diabetes for people with prediabetes. If you have taken any of the following blood tests, please provide the most recent date and results of your test below. A recent (within the past year) blood test meeting one of the following specifications:

If you took a blood test, please select the one taken and add the results in 19, 20, or 21.

Fasting Glucose (Date & Test Result)

Oral Glucose Tolerance (Date & Test Results)

21)Have you been diagnosed with gestational diabetes in a past pregnancy?

A1C (Date & Test Results)

Are you a man or a woman?

If you are a woman have you ever been diagnosed with gestational diabetes?

25)How old are you?

Do you have a mother, father, sister, or brother with diabetes?

Have you ever been diagnosed with high blood pressure?

Are you physically active?


Weight as of today:

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?

On a scale of 1 to 10, how confident are you that you could make a change if you wanted to?

On a scale of 1 to 10 how ready are you to make a change?

Do you have a physical or visual impairment?

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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.

Continue ONLY when finished. You will be unable to return or change your answers.