DPP Pre-Program Survey

1.Full Name (first and last):(Required.)
2.Address you'd like class materials mailed to:(Required.)
3.Preferred Email:(Required.)
4.Preferred Phone Number:(Required.)
5.Were you referred by a healthcare provider?(Required.)
6.What was the primary motivation for enrolling in this program?(Required.)
7.Would you prefer to participate in an in-person or virtual (over Zoom) group?
8.In the past year, have you had a fasting glucose of 100 - 125 mg/dl?(Required.)
9.In the past year, have you had a plasma glucose of 140 - 199 mg/dl?(Required.)
10.In the past year, have you had an A1C of 5.7 - 6.4?(Required.)
11.Have you had gestational diabetes with prior pregnancy?(Required.)
12.Do you have immediate family (parents or siblings) with diabetes?
13.Have you ever been diagnosed with high blood pressure?
14.Ethnicity (check one):(Required.)
15.Race (check all that apply):(Required.)
16.Gender (please select one):(Required.)
17.Sex assigned at birth:(Required.)
18.Date of Birth in MM/DD/YYYY format:(Required.)
19.Your age as of today:(Required.)
20.Education:(Required.)
21.Height (inches):(Required.)
22.Current weight (or best estimate):(Required.)
23.Physical activity minutes for the last week (or best estimate):(Required.)
 Readiness to Change Questionnaire
24.Where am I right now? 

Thinking about your physical activity and eating over the past three months, please answer the following questions. Please click the answer that best indicates how strongly you agree or disagree with the following statements. Check “Don’t Know or Refused” if you do not know or do not want to answer.(Required.)
Strongly Agree 
Agree 
 Not Sure 
 Disagree 
 Strongly Disagree 
 Don't Know or Refused 
I eat healthily
I get enough physical activity
I want to eat more healthily
I want to be more physically active
25.With respect to physical activity, how confident are you that you can make changes now?

Please click the answer that indicates how confident you are that you can make the following changes. Check “Don’t know or refused” if you do not know or do not want to answer.(Required.)
Sure I can
Think I can 
Not sure I can 
Don't think I can 
Don't know or refused 
Get physical activity more often 
Be physically active for longer time 
26.With respect to your eating habits, how confident are you that you can make changes now?

Please click the answer that indicates how confident you are that you can make the following changes. Check “Don’t know or refused” if you do not know or do not want to answer.(Required.)
 Sure I can
Think I can 
Not sure I can 
Don't think I can 
Don't know or refused
Eat more healthful food
 Overeat less often
27.Is there anything you would like to share that may have an impact on your success in the program? This may be from your past, present, or future. If you’re not comfortable writing it down, feel free to meet with your class facilitator individually.
28.Please explain your goals for the program (make it vivid, paint a picture).(Required.)