Diabetes Prevention Participant Registration Form

Diabetes Prevention Participant Registration Form
Patient Contact Details
Full Name

First NameLast Name
Date of Birth

DayMonthYear
SEX ( assigned at birth)
Are you:

ManWomanTransgender, non-binary, or another genderI do not identify with the choices provided
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
This is my:
Phone Number
This is my:
Phone Number
E-mail
example@example.com
What is your race or ethnicity? Select ALL that apply. You may enter additional details below:

American Indian or Alaska Native: Includes all individuals who identify with any of the original peoples of North, Central, and South America. It includes people who identify as American Indian or Alaska Native and groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Tlingit, etc. Provide additional details below: Enter, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc. _____________________Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc. Provide additional details below: Enter, for example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, Cambodian, Pakistani, Hmong, etc. _____Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, Bahamian, etc. Provide additional details below: Enter, for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, Ghanaian, South African, Barbadian, etc. __________________Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures. Examples of these groups include, but are not limited to, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, and Colombian. The category also includes groups such as Guatemalan, Honduran, Spaniard, Ecuadorian, Peruvian, Venezuelan, etc. Provide additional details below: Enter, for example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. ___________________Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the Middle East or North Africa. Examples of these groups include, but are not limited to, Lebanese, Iranian, Egyptian, Syrian, Moroccan, and Israeli. The category also includes groups such as Algerian, Iraqi, Kurdish, Tunisian, Chaldean, Assyrian, etc. Provide additional details below: Enter, for example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, Algerian, Iraqi, Kurdish, etc.______________________Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc. Provide additional details below: Enter, for example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, Palauan,Chuukese, Tahitian, etc. ______________________White: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Polish, and French. The category also includes groups such as Scottish, Norwegian, Dutch, Slavic, Cajun, Roma, etc. Provide additional details below: Enter, for example, German, Irish, English, Italian, Polish, French, Scottish, Norwegian, Dutch, etc. ___________________
Age:
Current Weight: pounds
How tall are you?
ex. 5 feet, 7 inches
Have you ever been diagnosed with type 2 diabetes?
Education: ( Check highest level of education received)

Less than grade 12 ( No high school diploma or GED)Grade 12 or GED ( High school graduate)Some college or technical schoolCollege or technical school graduate of higher
Please repond to the following questions to help us identify ways we can best assist you:
Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Do you have serious difficulty walking or climbing stairs?
Do you have difficulty dressing or bathing
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?
What was your main motivation for signing up for this program? Who or what convinced you that you should try it? ( Select one)

Healtcare ProfessionalBlood test resultPrediabetes Risk testSomeone at a community-based organization ( church, community center, fitness center, etc.)Family or friendsCurrent or past participant in the National DPP Lifestyle Change ProgramEmployer or employer's wellness planHealth insurance planMedia advertisements ( social media ,flyer, brochure, radio ad, billboard, etc. )Program Champion
Did a healthcare provider ask you to join this National DPP Lifestyle Change Program? ( select one)

Yes, a doctor/doctor's officeYes, other healthcare professionalYes, a pharmacistNo
Who is covering the cost for this program? ( Select one)

MedicareMedicaidPrivate /commercial insurerSelf-payDual Eligible ( Medicare and Medicaid)Grant fundingEmployerFree of chargeGovernment/MilitaryVenture capital
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 test listed below, please provide the most recent date and your results of your test below. A recent ( within the past year) .

Please upload a image of lab test below ( Hemoglobin A1c, Fasting Glucose, or Oral glucose Tolerance test)
Fasting Glucose and date
ex. 126 mg/dL, 07/31/2023
Oral Glucose Tolerance and date
ex. 180 mg/dL, 07/31/2023
A1c and date
ex. 8%, 07/31/2023
Have you been diagnosed with gestational diabetes in a past pregnancy?

YesNoNot SureNot Applicable
Prediabetes Determined by Risk Test score
In case of Emergency
Emergency Contact Name
Phone Number
Medicare ID:
Take a photo of your Insurance card front and back
Date

MonthDayYear
Date
By signing below, you acknowledge and give approval for Epic Care Pharmacy, it's affiliates, assignees and licensees to :

Disclose the results collected during the Diabetes Prevention Program sessions, including weights, attendance, and other health information that may be collected, to referring physicians, certifying and funding organizations will also be provided data for purposes of program administration, planning and evaluation purposes.
Signature

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Please upload a image of lab result within the last 12 months ( Hemoglobin A1c, Fasting Glucose, or Oral glucose Tolerance test)
Should be Empty:

Diabetes Prevention Participant Registration Form

Patient Contact Details

Please repond to the following questions to help us identify ways we can best assist you:

In case of Emergency