Use this form to let us know your interest in our Diabetes Prevention Program (DPP). We are also requesting some information about you to see if you qualify.

The 12-month DPP will be forming another cohort to begin January 2020. 

Days: Wednesdays, starting Jan. 15
Time: Noon-1 p.m.
Location: The Grove (Surge III), Room 1310

Meetings are weekly for the first three 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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* 7. Please choose your University affiliation.

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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 is your age?

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* 13. What is your height?

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* 14. What is your current weight?

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

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

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

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* 18. Have you been told by a healthcare professional that you are prediabetic or have you suffered from gestational diabetes during a preganancy?

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

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* 20. Are you comfortable in a group setting?

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

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* 22. Please indicate your ethnicity:

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

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