DPP Pre-Program Survey Question Title * 1. Full Name (first and last): Question Title * 2. Address you'd like class materials mailed to: Question Title * 3. Preferred Email: Question Title * 4. Phone Number: Question Title * 5. Were you referred by a healthcare provider? Yes, a doctor/doctor's office Yes, a health coach Yes, other healthcare professional No Question Title * 6. What was the primary motivation for enrolling in this program? 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) Question Title * 7. Would you prefer to participate in an in-person or virtual (over Zoom) group? In-person Virtual (over Zoom) No preference Question Title * 8. In the past year, have you had a plasma glucose of 140-199? Yes No Unsure Question Title * 9. Have you had gestational diabetes with prior pregnancy? Yes No Question Title * 10. Do you have immediate family (parents or siblings) with diabetes? Yes No Question Title * 11. Have you ever been diagnosed with high blood pressure? Yes No Question Title * 12. Ethnicity (check one): Hispanic or Latino Not Hispanic or Latino Prefer not to answer Question Title * 13. Race (check all that apply): American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Prefer not to answer Question Title * 14. Gender (please select one): Female Male Transgender Prefer not to answer Question Title * 15. Sex assigned at birth: Female Male Question Title * 16. Date of Birth in MM/DD/YYYY format: Question Title * 17. Your age as of today: Question Title * 18. Education: No high school diploma or GED High school graduate Some college or technical school College graduate Prefer not to answer Question Title * 19. Height (inches): Question Title * 20. Current weight (or best estimate): Question Title * 21. Physical activity minutes for the last week (or best estimate): Readiness to Change Questionnaire Question Title * 22. 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. Strongly Agree Agree Not Sure Disagree Strongly Disagree Don't Know or Refused I eat healthily I eat healthily Strongly Agree I eat healthily Agree I eat healthily Not Sure I eat healthily Disagree I eat healthily Strongly Disagree I eat healthily Don't Know or Refused I get enough physical activity I get enough physical activity Strongly Agree I get enough physical activity Agree I get enough physical activity Not Sure I get enough physical activity Disagree I get enough physical activity Strongly Disagree I get enough physical activity Don't Know or Refused I want to eat more healthily I want to eat more healthily Strongly Agree I want to eat more healthily Agree I want to eat more healthily Not Sure I want to eat more healthily Disagree I want to eat more healthily Strongly Disagree I want to eat more healthily Don't Know or Refused I want to be more physically active I want to be more physically active Strongly Agree I want to be more physically active Agree I want to be more physically active Not Sure I want to be more physically active Disagree I want to be more physically active Strongly Disagree I want to be more physically active Don't Know or Refused Question Title * 23. 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. 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 Get physical activity more often Sure I can Get physical activity more often Think I can Get physical activity more often Not sure I can Get physical activity more often Don't think I can Get physical activity more often Don't know or refused Be physically active for longer time Be physically active for longer time Sure I can Be physically active for longer time Think I can Be physically active for longer time Not sure I can Be physically active for longer time Don't think I can Be physically active for longer time Don't know or refused Question Title * 24. 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. Sure I can Think I can Not sure I can Don't think I can Don't know or refused Eat more healthful food Eat more healthful food Sure I can Eat more healthful food Think I can Eat more healthful food Not sure I can Eat more healthful food Don't think I can Eat more healthful food Don't know or refused Overeat less often Overeat less often Sure I can Overeat less often Think I can Overeat less often Not sure I can Overeat less often Don't think I can Overeat less often Don't know or refused Question Title * 25. 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. Question Title * 26. Please explain your goals for the program (make it vivid, paint a picture). Done
