Diabetes Prevention Class Survey
Please answer the following questions to help us understand your needs and experiences.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about our Diabetes Prevention Classes?
*
Please Select
Doctor or healthcare provider
Friend or family member
Online search
Social media
Community event
Other
Have you ever been diagnosed with any of the following:
Pre-Diabetes
Type 1 Diabetes
Type 2 Diabetes
None
If yes, when did you last receive your lab results?
Date of Birth:
Are you a man or a woman?
*
Man
Woman
If you are a woman, have you ever had gestational diabetes ?
*
Yes
No
Do you have a mother, father, sister, or brother with diabetes ?
*
Yes
No
Have you ever been diagnosed with High Blood Pressure ?
*
Yes
No
Are you physically active?
*
Yes
No
What is your current weight & height?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How likely are you to recommend these classes to others?
*
Not likely
1
2
3
4
5
6
7
8
9
Very likely
10
1 is Not likely, 10 is Very likely
Education Level
High School Grad (GED)
Some College or Tech College
4 Year College Degree
Other
What changes or improvements would you like to see in yourself?
Submit Survey
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