Virtual Lifestyle Change Program

Registration Form

Intertribal Wellness Lifestyle Change Program: Prevent Type 2 Diabetes Program
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How do you prefer to be contacted?*

TextEmailPhone callEither option
What is your race/ethnicity?*

African AmericanAmerican IndianAsianHawaiianWhite
Birth date*

MonthDayYear
Date
Are you a Wyoming Resident?

YesNo
Do you have access to a scale?

YesNo
Are you self-referring into the Intertribal Wellness Lifestyle Change Program?

YesNo
Are you referred into the Intertribal Wellness Lifestyle Change program by your physician?

YesNo
Referred by: blanks
Have you taken the Diabetes Risk Test?

YesNo
Diabetes Risk Test
What did you score?
Do you know your Hemoglobin A1C (HbA1c)*

YesNo
If so, what is your latest Hemoglobin A1C (HbA1c) reading?
What is your current weight?*
What is your height?*
Have you been diagnosed with Type 1 or Type 2 Diabetes?

YesNoNot sure
Date of Diagnosis Date
Do you have High Blood Pressure above (120/80)?

YesNo
Do you have a smart phone device?*

YesNo
What kind of smart watch do you have?

SamsungGarminAppleFit BitWithingsOther
Who is your medical insurance provider?*

CignaBlue Cross Blue ShieldMountain Health Co-opMedicaidMedicareUninsuredOther
Other: blanks
Education

Some Elementary, Middle or High SchoolHigh School Graduate or GEDSome College or Technical SchoolFour Year College Degree
Are you willing and able to commit to a year-long program that meets once a week for the first two months, twice a month for the next four months and then once per month for the remainder of the program?*

YesNo
All information will be confidential and only shared with authorized CDC representatives for the National Diabetes Prevention Program.
Date

MonthDayYear
Date
Signature*
Should be Empty:

Registration Form