Participant information
Your Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Mobile Phone
Home Phone
Work Phone
Text allowed:
Mobile
Home
Work
NONE
Address
City
State
Zip
County
How would you prefer to be contacted?
Phone call
Text
Email
Other
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Provider Information (Optional)
This will be used to access and share Lab information and progress in the program.
Primary Provider Name
Name of Facility
Phone Number
Address
City
State
Zip
Information to be Released ( further documentation to be provided):
Labs (Cholesterol, Glucose, and A1C), Blood Pressure, Weight, and associated medications can be released TO Teton County Health Department from the previously stated provider
Labs (Cholesterol, Glucose, and A1C), Blood Pressure and Weight can be released FROM Teton County Health Department to the previously stated provider
No Information to be released
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Demographic Information
This is only used to help with resources, or for statistic information for the state.
Distance Traveled to DPP location
Sex (assigned at birth)
Male
Female
Declined
Gender (How do you describe yourself)
Female
Male
Transgender
Declined
Race/Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hawaiian Native or Pacific Islander
White
Multiple Races
Declined
Education
Some High School
High School Graduate
Some College or vocational school
College Degree
Declined
Household Income
Less than $15,000
$15,000 - $24,999
$25,000 - $49,999
$50,000 - $74,999
$75,000 or more
Declined
Employment Status
Full Time
Part Time
Unemployed
Retired
Declined
Which of the following prompted you to enroll in the DPP?
Prediabetes risk test
Non-primary health professional
Community Health Worker
Employer Wellness Program
Brochure/Postcard
Insurance Company
Social Media
Newspaper
Blood test results
Primary Care Provider
Former DPP participant
Flyer
Website
Mailing
Friend/Family
Newsletter
WIC
Radio
TV
Coworker
Medicaid
What Type of Insurance coverage do you have?
Alliegiance
BCBS
Cigna
Dual Coverage (Medicare/Medicaid)
Medicaid
Medicare
Uninsured
United HealthCare
Unknown
Declined
Other
Active Duty
Yes
No
Declined to answer
Unknown
Medical/Disability
Yes
No
Declined
Unknown
Diagnosed with Arthritis
Deaf or has serious hearing difficulty
Blind or has serious difficulty seeing, even when wearing glasses
Because of physical, mental, or emotional condition, has serious difficulty concentrating, remembering, or making decisions
Has serious difficulty walking or climbing stairs
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Weight
Height
Diagnosis
Yes
No
Declined
Unknown
Hypertension
Dyslipidemia (high cholesterol)
Impaired Fasting Glucose
History of Gestational Diabetes
End Stage Renal Disease
One or both natural parents had diabetes
Do you have Asthma
Tobacco Use
Current User
Former User
Never Used
Declined
Unknown
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Liability Release
I acknowledge that my participation is expressly conditioned on my agreement to each of the terms of this document. I acknowledge and agree as follows:1. My participation in the Healthy Tracks (Diabetes Prevention Program DPP) offered by the Teton County Health Department is a voluntary activity. I voluntarily assume full responsibility for any injury, risks, or losses that may occur due to my participation in the class or program.2. Physical exercise, sports, and recreational activities may cause injury. I understand there is an inherent risk of injury when choosing to participate in any physical exercise, sport, wellness, and/or recreational activities. I understand that the class or program may involve strenuous physical activity, and I hereby affirm that I am in good health and sufficient physical condition to properly participate in the class or program. I have been advised by Teton County Health Department to consult with a healthcare provider before I undertake any physical exercise program.I have read and fully understand this Acknowledgement set forth above, including consulting my healthcare provider to participate in this program.
Name
First Name
Last Name
Signature
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