Registration Form

Prevent T2 For All is an inclusive diabetes prevention program for individuals looking to make lifestyle changes (T2 is Type 2 Diabetes). This year-long program will provide tips, strategies, and resources to help participants prevent or delay the onset of diabetes. Topics covered include healthy eating and physical activity for weight loss and stress management.

Classes are free and will be held in the Wet Classroom on Tuesdays from 12-1 PM.  Space is limited for 12 eligible participants.

This information will be used for recruitment and data collection purposes only.  It will not be shared without your permission.

For additional questions, please contact Rebecca Cline at rebeccac@lakeshore.org or 205-313-7420.  After completion, you will receive a follow-up confirmation if you meet the eligibility requirements to participate in this program.

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* 1. What is your contact information?

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* 2. Are you currently a member of Lakeshore Foundation?

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* 3. What is your current weight in pounds?

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* 4. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5'4".

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* 5. What is your gender?

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* 6. How old are you?

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* 7. Which race/ethnicity best describes you? (Please choose only one).

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* 8. Do you have a previous diagnosis of Type 1 or Type 2 diabetes?

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* 9. Have you had a blood test result in the prediabetes range within the past year of one of the following? (Prediabetes can be diagnosed via oral glucose tolerance tests, fasting blood glucose tests, or an A1C test. Blood-based testing is the most accurate way to determine if a patient has prediabetes).

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* 10. Are you deaf, or do you have serious difficulty hearing?

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* 11. Are you blind, or do you have serious difficulty seeing, even when wearing glasses?

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* 12. Because of physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

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* 13. Do you have serious difficulty walking or climbing stairs?

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* 14. Do you have difficulty dressing or bathing?

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* 15. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

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* 16. Will you need any of the following accommodations listed below?

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* 17. What is your preferred form of communication?

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