NDPP Survey Participant Information Survey for NDPP Sign me up for the Diabetes Prevention Program - Sessions on internet/Zoom Evening is best for me Daytime is best for me other - contact me First NameLast NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email PhonePlease take the CDC Risk Test here https://www.cdc.gov/prediabetes/takethetest/ and enter the number in the box belowI am over 18 Yes No Date of Birth MM slash DD slash YYYY HeightWeightAre you: Female Male Non-Binary Prefer not to answer Please specify your ethnicity/race American Indian or Native Alaskan Asian Black of African-American Hispanic/Latino Native Hawaiian or other Pacific Islander White Two or more Are you a veteran? Yes No With regards to employment are you: Working full time Working part time Unemployed, not looking Segregated work/day program Looking for work Student or in program Other (1705 NPDD grant-funded participants) As part of the program you can receive tips and support via text messages. We believe this will enhance your program experience, however, if you DO NOT want to receive text messages, please check below. NO text messages Please provide your mobile/cell phone number if you wish to receive these program-support text messages. The number will be used for texting purposes only and not shared with any third parties.Have you ever been told by a health care provider that you have or have had any of the following chronic condition? Please mark all that apply.* Alzheimer's or related dementia Arthritis/Rheumatic Disease Breathing/Lung Disease (e.g. Asthma, Brochitis) Cancer or Cancer Survivor Chronic Pain Depression or Anxiety Disorders Diabetes Heart Disease High Cholesterol Hypertension (High Blood Pressure) Multiple Sclerosis Osteoporosis (Low Bone Density) Prediabetes Stroke Other Chronic Condition None No Chronic Condition Do you have any of the following disabilities? Cognitive - intellectual disability, traumatic & other brain injuries, autism, learning disability Physical - spinal injury, neruomuscular, orthopedic, Epilepsy, HIV/AIDS, amputation, other Mental - mental illness, emotional behavior, substance abuse, other mental illness Sensory - blindness, low vision, deafness, deaf and blind Other Chronic Condition if not listedAre you deaf or do you have serious difficulty hearing? Yes No Are you blind or do you have serious difficulty seeing, even when wearing glasses? Yes No Because of a physical, mental or emotional condition do you have serious difficulty concentrating, remembering or making decisions? Yes No Do you have serious difficulty walking or climbing stairs? Yes No If you answered yes to any of the above questions 7-12 do you require accommodations? Yes No If yes, please list the accommodationsHow did you hear about this program? Recommended by health care provider or physician Flyer/Brochure Health Fair Informational Session Info in health care provider or physician office Recommended by Friend Newspaper (online or print) Other If other please explainIf recommended by health care provider were you formally referred to the program? Yes No Have you had a blood test in the prediabetes range within the last year? Yes No If you had a result in the prediabetes range please provide the results below or to the Lifestyle Coach within the next monthHave you had gestational diabetes? (diabetes while pregnant) Yes No What is the highest degree or level of school completed? Some Elementary, Middle or High School High School Graduate or GED Some College or Technical School Associate Degree Bachelor's Degree Masters or Professional Degree Doctorate degree What is the primary source of your health care coverage A plan purchased through an your employer or union A plan that you or another family member buys on your own Medicare Medicaid or other state program TRICARE (formally CHAMPUS), VA or military Some other source None (no coverage) If some other source, please specifyOverall, would you say your general health is: Excellent Very Good Good Fair Poor I am motivated to improve my health Strongly Agree Agree Disagree Strongly Disagree Signature, please type in your first and last nameSection Break
