Diabetes Prevention Program Registration

Please select which workshop you would like to join

Full Name:

*3)Date of Birth


Street Address:

City, State

Zip code:

Phone Number:


How old are you?

Are you a man or a woman?

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

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?

survey image
survey image

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.