Group Lifestyle Balance Program (Diabetes Prevention Program)
Classes will begin Thursday June 6th at St. Paul's Lutheran Church 7-8pm Participant Registration Form
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
Email
*
example@example.com
Gender
*
Female
Male
Program Eligibility Questions
We wish everyone could participate in this group program for its health benefits, but with a limited number of spots and certain eligibility criteria a participant must meet in order for the program to track their progress, we kindly ask you to answer the following questions. (For additional information on access to program, please see bottom of form.)
Must be able to check YES to all of these:
*
I am 18 years of age or older
I am overweight
I am not pregnant
I do not currently have Type 1 Diabetes or Type 2 Diabetes
Must meet ONE of these (choose one)
*
I have been told by my doctor I have prediabetes
I have had gestational diabetes in a prior pregnancy
I am considered high-risk (Take the quiz www.cdc.gov/prediabetes/risktest )
Lifestyle Change Readiness
Please rank the following questions with how ready and willing you are to make the following lifestyle changes. Scale: 1=not ready or willing at all --> 5=extremely ready and willing
Commit to a positive change in your diet and exercise habits
*
1
2
3
4
5
Attend group sessions regularly & actively particpate
*
1
2
3
4
5
Monitor daily food intake & physical activity for one year
*
1
2
3
4
5
Track and record information for program progress
*
1
2
3
4
5
Set and work towards program & personal goals during the program
*
1
2
3
4
5
If you do not meet eligibility or are unsure if you qualify...
Crestwood Pharmacy is committed to being a health and wellness resource for their patients and community. The following options may apply to you: A) If you do not meet the criteria to be eligible for us to track your progress during this year-long program, there may still be spots available for you to attend the program classes and actively participate and set personal goals. B) If the class is full, we do have lifestyle programs available through the pharmacy to work one on one with one of our lifestyle pharmacists.
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Submit
Program Staff Use Only
For internal use only, field not available to patients
Reviewed by program staff member & notes on eligibility and/or willingness scale
Should be Empty: