Please use this form to let us know your interest in our Diabetes Prevention Program (DPP). We are also requesting some information about you to verify that you qualify.

Days: Once a week (day TBD) 
Time: Noon-1 p.m.
Location: The group will meet remotely via zoom.

Meetings are weekly for the first four months, then biweekly thereafter. 
Basic qualifications are based on BMI, lifestyle habits and readiness to change.
 

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* 1. First Name:

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* 2. Last Name:

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* 3. Email Address:

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* 4. Phone Number:

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* 5. Where do you work at UC Davis?

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* 6. Please choose your University affiliation.

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* 7. What department do you work in?

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* 8. Are you a member of a union?

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* 9. How many years have you worked at UC Davis?

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* 10. Did you receive a UC Health DPP invitation letter?

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* 11. How did you hear about the Diabetes Prevention Program?

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* 12. What (or who) motivated you the most to explore the Diabetes Prevention Program (DPP)?

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* 13. What is your age?

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* 14. What is your height?

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* 15. What is your current weight?

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* 16. Have you lost weight in the past?  How did you do it and were you successful keeping the weight off?

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* 17. Currently, how many minutes per week do you exercise at moderate intensity (i.e. brisk walk)?

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* 18. Do you have your current A1c lab test result?

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* 19. Do you have a mother, father, sister, or brother with diabetes?

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* 20. Have you been told by a healthcare professional that you are prediabetic? 

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* 21. Have you ever been diagnosed with Gestational Diabetes during a pregnancy?

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* 22. Have you ever been diagnosed with high blood pressure?

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* 23. Are you comfortable in a group setting?

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* 24. Please indicate which Health Plan you participate in:

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* 25. Please indicate your sex (assigned at birth)

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* 26. Please indicate you gender (how you describe yourself)

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* 27. Please indicate your ethnicity:

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* 28. Please indicate the level of education you have completed:

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