Demographics:

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* 1. First Name 

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* 2. Last Name 

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* 3. Preferred Phone Number

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* 4. Email Address 

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* 5. Date of Birth in MM/DD/YYYY format 

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* 6. Gender (please select one)

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* 7. Please enter your height in feet and inches 

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* 8. Please enter your current weight (weight taken today)

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* 9. What county do you live in?

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* 10. Are you a ThedaCare employee?

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* 11. Are you a spouse or dependent of a ThedaCare employee?

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* 12. Who is your Primary Care Physician (PCP)?

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* 13. What is your Healthcare Plan?

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* 14. How did you hear about ThedaCare's Lifestyle Programs?

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* 15. Which program are you interested in joining? If unsure, please leave blank.

Diabetes:

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* 16. Do you currently have diabetes?

If no, skip to question 18.

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* 17. If yes, Type I or II

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* 18. If yes, do you take medication to manage diabetes?

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* 19. Check yes or no:

  Yes  No
Do you smoke or use tobacco products?
Are you currently pregnant?
Are you currently taking medication to control blood sugar?
Have you ever been told you have high cholesterol?
Are you currently taking medication for blood pressure?
Do you have immediate family (parents or siblings) with diabetes?
Are you physically active?
Have you ever been diagnosed with high blood pressure?
Have you ever been told you have high triglycerides?
Have you had gestational diabetes with prior pregnancy?

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* 20. In the past year, have you...

  Yes No Unsure
Had a fasting blood sugar of 100+?
Had a plasma glucose of 140-199 (an impaired glucose tolerance test)?
Had a HbA1C of 5.7-6.4?
Had a blood pressure reading of 120/70 or higher?
Food Security:

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* 21. Within the past 12 months... 

  Yes No Prefer not to answer
Have you worried that your food would run out before getting money to buy more?
Has the food you've been buying not lasting as long as it needs to?

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