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DPP Pre-Program Survey
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1.
Full Name (first and last):
(Required.)
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2.
Address you'd like class materials mailed to (please include ZIP Code):
(Required.)
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3.
Preferred Email:
(Required.)
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4.
Preferred Phone Number:
(Required.)
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5.
What was the primary motivation for enrolling in this program?
(Required.)
Healthcare professional
Blood test results
Community based organization
Family or friends
Employer or employer's wellness plan
Health insurance plan
Flyer or email promotion
Other (please specify)
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6.
Were you referred by a healthcare provider?
(Required.)
Yes, a doctor/doctor's office
Yes, a health coach
Yes, other healthcare professional
No
7.
Would you prefer to participate in an in-person or virtual (over Zoom) group?
In-person
Virtual (over Zoom)
No preference
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8.
In the past year, have you had a fasting glucose of 100 - 125 mg/dl?
(Required.)
Yes
No
Unsure
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9.
In the past year, have you had a plasma glucose of 140 - 199 mg/dl?
(Required.)
Yes
No
Unsure
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10.
In the past year, have you had an A1C of 5.7 - 6.4?
(Required.)
Yes
No
Unsure
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11.
Have you had gestational diabetes with prior pregnancy?
(Required.)
Yes
No
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12.
Do you have immediate family (parents or siblings) with diabetes?
(Required.)
Yes
No
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13.
Have you ever been diagnosed with high blood pressure?
(Required.)
Yes
No
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14.
Please respond to the following questions to help us identify ways we can best assist you:
(Required.)
Yes
No
Prefer not to answer
Are you deaf or do you have serious difficulty hearing?
Yes
No
Prefer not to answer
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Yes
No
Prefer not to answer
Do you have serious difficulty concentrating, remembering, or making decisions due to a physical, mental, or emotional condition?
Yes
No
Prefer not to answer
Do you have serious difficulty walking or climbing stairs?
Yes
No
Prefer not to answer
Do you have difficulty dressing or bathing?
Yes
No
Prefer not to answer
Do you have difficulty doing errands alone due to a physical, mental, or emotional condition?
Yes
No
Prefer not to answer
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15.
Ethnicity (check one):
(Required.)
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
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16.
Race (check all that apply):
(Required.)
American Indian or Alaska Native
Asian or Asian American
Black or African American
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
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17.
Sex assigned at birth:
(Required.)
Female
Male
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18.
Gender (please select one):
(Required.)
Female
Male
Nonbinary
Prefer not to answer
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19.
Date of Birth in MM/DD/YYYY format:
(Required.)
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20.
Your age as of today:
(Required.)
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21.
Education:
(Required.)
No high school diploma or GED
High school graduate
Some college or technical school
College graduate
Prefer not to answer
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22.
Height (inches):
(Required.)
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23.
Current weight (or best estimate):
(Required.)
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24.
Physical activity minutes for the last week (or best estimate):
(Required.)
Readiness to Change Questionnaire
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25.
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
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Don't Know or Refused
I get enough physical activity
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Don't Know or Refused
I want to eat more healthily
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Don't Know or Refused
I want to be more physically active
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Don't Know or Refused
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26.
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
Sure I can
Think I can
Not sure I can
Don't think I can
Don't know or refused
Be physically active for longer time
Sure I can
Think I can
Not sure I can
Don't think I can
Don't know or refused
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27.
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
Sure I can
Think I can
Not sure I can
Don't think I can
Don't know or refused
Overeat less often
Sure I can
Think I can
Not sure I can
Don't think I can
Don't know or refused
28.
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.
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29.
Please explain your goals for the program (make it vivid, paint a picture).
(Required.)
