Welcome to The Diabetes Prevention Program. Please fill out the intake form to complete your registration.

For more info or assistance please call 313-654-3212

For more information on the resources provided by ACCESS Community Health and Research Center, go to: www.accesscommunity.org.

Name
Address
Have you ever attended a Diabetes Prevention Program in the past?
Have you been told by a health care provider that you have pre-diabetes or elevated blood sugar?
Diagnosis of prediabetes or GDM based on:
Have you been diagnosed with the following? (check all that apply)
Race (check all that apply):
Education (check highest level of education received)
Enrollment (check who referred you to this program)
1. Do you have a mother, father, sister, or brother with diabetes?
2. Have you ever been diagnosed with high blood pressure?
3. Are you physically active?
Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Do you have serious difficulty concentrating, remembering, or making decisions because of a physical, mental or emotional condition?
Do you have serious difficulty walking or climbing stairs?
Do you have difficulty dressing or bathing?
Do you have difficulty doing errands alone such as visiting a doctor's office or shopping because of a physical, mental or emotional condition?
Do you require any special accommodations to participate in the Diabetes Prevention Program?
Have you used tobacco/tobacco-like products (such as e-cigarettes, cigars, chewing tobacco, pipe smoking, etc.) within the previous 30 days?
Tracking your weight is an important part of the program and participants are required to weigh themselves once a week. Do you need ACCESS to provide you with a bathroom scale?
Insurance Carrier and Policy Number

By signing below, I agree to disclose the results collected during the Diabetes Prevention Program sessions, including weights, attendance, and any other health information that may be collected, to referring physicians.  Certifying and funding organizations will also be provided data for purposes of program administration, planning and evaluation purposes. 

Utilize my photographs, personal narrative, interviews or video recording of my participation in the diabetes prevention program for any and all purposes.

Use your mouse or finger to draw your signature above

Congratulations!

You have almost completed the registration form for the Diabetes Prevention Center. Simply click on "Submit Form" below to complete the process, and then come to class! We hope to see you there.

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