Lifestyle Change Programs – Workshop Registration

Please don't fill out this input box.

Which program are you interested in Attending? (Check One):*

Diabetes Prevention Program-Prevent T2

Your Diabetes, Your Heart

Active Living After Cancer

Hypertension Workshops

Blood Pressure Management

First Name*

Last Name*

Address*

City/State*

Zip code*

Phone*

Email*

Contact Preference*

Phone

Mail

Gender*

Male

Female

Date of Birth*

Ethnicity*

Hispanic

Non-Hispanic

Race (select all that apply)*

African American/Black

American Indian/Alaskan Native

Asian

Native Hawaiian/Another Pacific Islander

White

Highest level of education earned*

Less than High School

High School Graduate

Some College

College Graduate or more

Preferred Language*

English

Spanish

Weight - lbs.*

Height - Ft*

Date of most recent blood pressure reading

Most recent blood pressure reading:

Systolic

Diastolic

Are you currently taking blood pressure medication? *

Yes

Don't Know

Have you been diagnosed with cardiovascular disease?*

Yes

Don't Know

Do you currently smoke?*

Yes

Don't Know

Have you been diagnosed with high cholesterol?*

Yes

Don't Know

Have you been diagnosed with kidney disease?*

Yes

Don't Know

Have you been diagnosed with Type 2 Diabetes?*

Yes

Don't Know

Have you been diagnosed with prediabetes?

Yes

Don't Know

Are you a cancer survivor?

Yes

Don't Know

If yes, are you currently undergoing treatment for cancer (chemotherapy or radiation)?

Yes

Don't Know

Are you caregiver for anyone suffering from cancer?

Yes

Don't Know

Additional Comments

Please download the Media Consent Form, sign and scan (or take a photo) and email the consent form to lifestylechangeprograms@uthct.edu