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Lifestyle Application
Demographics:
*
1.
First Name
(Required.)
*
2.
Last Name
(Required.)
*
3.
Preferred Phone Number
(Required.)
*
4.
Email Address
(Required.)
*
5.
Date of Birth in MM/DD/YYYY format
(Required.)
*
6.
Gender (please select one)
(Required.)
Male
Female
Nonbinary
Prefer not to answer
*
7.
Please enter your height in feet and inches
(Required.)
*
8.
Please enter your current weight (weight taken today)
(Required.)
*
9.
What county do you live in?
(Required.)
Outagamie
Calumet
Winnebago
Other (please specify)
*
10.
Are you a ThedaCare employee?
(Required.)
Yes
No
11.
Are you a spouse or dependent of a ThedaCare employee?
Yes
No
12.
Who is your Primary Care Physician (PCP)?
*
13.
What is your Healthcare Plan?
(Required.)
Medicaid
Medicare
ThedaCare/Robin
Other (please specify)
*
14.
How did you hear about ThedaCare's Lifestyle Programs?
(Required.)
Doctor/PCP
Family or friend
Employer newsletter
Flyer or email promotion
Other (please specify)
15.
Which program are you interested in joining? If unsure, please leave blank.
Diabetes:
*
16.
Do you currently have diabetes?
(Required.)
Yes
No
If no, skip to question 18.
17.
If yes, Type I or II
Type I
Type II
18.
If yes, do you take medication to manage diabetes?
Yes
No
19.
Check yes or no:
Yes
No
Are you currently pregnant?
Yes
No
Have you ever been diagnosed with high blood pressure?
Yes
No
Have you ever been told you have high triglycerides?
Yes
No
Do you have immediate family (parents or siblings) with diabetes?
Yes
No
Have you had gestational diabetes with prior pregnancy?
Yes
No
Have you ever been told you have high cholesterol?
Yes
No
Are you currently taking medication for blood pressure?
Yes
No
Are you currently taking medication to control blood sugar?
Yes
No
Do you smoke or use tobacco products?
Yes
No
Are you physically active?
Yes
No
20.
In the past year, have you...
Yes
No
Unsure
Had a fasting blood sugar of 100+?
Yes
No
Unsure
Had a plasma glucose of 140-199 (an impaired glucose tolerance test)?
Yes
No
Unsure
Had a HbA1C of 5.7-6.4?
Yes
No
Unsure
Had a blood pressure reading of 120/70 or higher?
Yes
No
Unsure
Food Security:
21.
Within the past 12 months...
Yes
No
Prefer not to answer
Have you worried that your food would run out before getting money to buy more?
Yes
No
Prefer not to answer
Has the food you've been buying not lasting as long as it needs to?
Yes
No
Prefer not to answer
