Diabetes Self Management Program Registration

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1. What type of Diabetes do you have? (Required.)

Type 1

Type 2

Gestational

I don't know

I don't have diabetes but I'm here for someone else

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2. What is your last A1c result? (Required.)

Below 7

7 - 9

10 or above

I don't know

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3. How often do you monitor your blood sugars... (Required.)

A few times per day

Once per day

Sometimes per week

Rarely

Never

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4. Do you use a continuous glucose monitor? (Required.)

Yes

I don't know

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5. Do you use an insulin pump? (Required.)

Yes

I don't know

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6. What medications do you use to control your diabetes? (Check all that apply) (Required.)

Injectables (Ozempic, Tradjenta, etc)

Insulin

Pills

Natural remedies

I don't take medications for diabetes

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7. Who supports you the most with your diabetes? (Required.)

Family

Friends

Coworkers

No one

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8. Which of the items below represent the biggest challenge for you to control your diabetes? (Choose your top 3) (Required.)

Eating healthier

Exercising

Monitoring blood sugars

Getting good quality sleep

Managing stress

Taking medications

Problem solving

Other (please specify)

Your participation in these group meetings is completely voluntary. If you wish to discontinue attending the meetings, you may do so at any time. There is no obligation on your part to attend the meetings, and any decision you make to participate will have no impact on any medical treatment or plan of care with any provider at Montefiore Nyack Hospital. If you have any questions or concerns you can contact the Department Director at 845-587-1318.

By adding your full name and e-mail below 1. you authorize Montefiore Nyack Hospital to send invitations and meeting materials to your designated e-mail account and 2. you release Montefiore Nyack Hospital and the officers, directors, agents, employees and representatives of Montefiore Nyack Hospital from any and all liability which may arise from your participation in the Diabetes Self-Management Education Program, and/or from the information provided to you concerning such program, and/or from any other information provided by you to Montefiore Nyack Hospital.

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9. Please enter your full name and contact information below. (Required.)

Full name

E-mail

Phone number

Diabetes Self Management Program Registration

Question Title

* 1. What type of Diabetes do you have? (Required.)

Question Title

* 2. What is your last A1c result? (Required.)

Question Title

* 3. How often do you monitor your blood sugars... (Required.)

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* 4. Do you use a continuous glucose monitor? (Required.)

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* 5. Do you use an insulin pump? (Required.)

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* 6. What medications do you use to control your diabetes? (Check all that apply) (Required.)

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* 7. Who supports you the most with your diabetes? (Required.)

Question Title

* 8. Which of the items below represent the biggest challenge for you to control your diabetes? (Choose your top 3) (Required.)

Question Title

* 9. Please enter your full name and contact information below. (Required.)

1. What type of Diabetes do you have? (Required.)

2. What is your last A1c result? (Required.)

3. How often do you monitor your blood sugars... (Required.)

4. Do you use a continuous glucose monitor? (Required.)

5. Do you use an insulin pump? (Required.)

6. What medications do you use to control your diabetes? (Check all that apply) (Required.)

7. Who supports you the most with your diabetes? (Required.)

8. Which of the items below represent the biggest challenge for you to control your diabetes? (Choose your top 3) (Required.)

9. Please enter your full name and contact information below. (Required.)