MedsPLUS DPP Registration Form – MedsPLUS Consulting, LLC

Gender

Male

Female

Age

Height (Feet & Inches)

Weight

BMI

Do you have any medical restrictions for physical activity?

No

Yes

If you answered Yes to the above, please describe

How did you learn about MedsPLUS DPP?

How are you eligible for the Diabetes Prevention Program? (Check all that apply)

Blood test (fasting, 2-hour glucose tolerance test or A1c)

Gestational Diabetes in previous pregnancy (GDM)

CDC Prediabetes Risk Quiz (score > 9)

Don’t know

Ethnicity - Are you Hispanic or Latino? (Check one)

No

Yes

Prefer not to answer

Race - How do you describe your race? (Check all that apply)

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

What type of health insurance do you have?

Private

Medicare

Medicaid

Uninsured

If you answered Private to the above, please type the name of your provider