Lifestyle Change Participant Form

Name

First Last

Work Phone(Required)

Email(Required)

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Name

First Last

Emergency Contact Phone(Required)

Physician's Name

First Last

Physician's Phone(Required)

Enrollment motivation: At enrollment, participants are asked who/what motivated them the most to sign up for this program; what was the most influential factor?(Required)

Enrollment by healthcare professional: At enrollment, participants are asked if a healthcare professional asked them to join this National DPP LCP.(Required)

Have you ever been told you have Diabetes?(Required)

Did a Physician refer participant?(Required)

Does participant have Medicare?(Required)

Does participant have Insurance?(Required)

If yes, list company(Required)

Is participant priority population?(Required)

Priority population includes men, Medicare beneficiary, visual or physical disability, African American, Asian American, Hispanic, Native American, Alaska Native, Pacific Islander

Qualification

Fasting glucose

Plasma glucose

A1c

Date of last A1c test

History of Gestational Diabetes?(Required)

Race(Required)

If Hispanic or Latino(Required)

Sex(Required)

Sex assigned at birth

Gender Identity

Age(Required)

Education Level(Required)

Height(Required)

Initial Weight(Required)

BMI

Goal Weight(Required)

How did you hear about the program?

What day of the week would you be able to attend?(Required)

Which class would you prefer(Required)

Determine Prediabetes Risk Test Score

Prediabetes Risk Test score (see link above)(Required)

Where am I right now?

Thinking about your physical activity and eating over the past three months, please answer the following questions. Please select an option to indicate how strongly you agree or disagree with the following statements. (Select "Don't know or refused" if you do not know or do not want to answer.)

I Eat Healthily(Required)

I Get Enough Physical Activity(Required)

I Want to Eat More Healthily(Required)

I Want to Be More Physically Active(Required)

How confident are you that you can make changes now?

Please select an option to indicate how confident you are that you can make the following changes. (Select "Don't know or refused" if you do not know or do not want to answer.)

Get Physical Activity More Often(Required)

Be Physically Active for Longer Time(Required)

Eat More Healthful Food(Required)

Overeat Less Often(Required)

CAPTCHA

Lifestyle Change Participant Form

Qualification

Where am I right now?

How confident are you that you can make changes now?

Choctaw Nation of Oklahoma

1802 Chukka Hina, Durant, OK 74701 · 800-522-6170