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Lifestyle Change Programs – Workshop Registration

Which program are you interested in Attending? (Check One):*
Contact Preference*
Gender*
Ethnicity*
Race (select all that apply)*
Highest level of education earned*
Preferred Language*
Most recent blood pressure reading:
Are you currently taking blood pressure medication? *
Have you been diagnosed with cardiovascular disease?*
Do you currently smoke?*
Have you been diagnosed with high cholesterol?*
Have you been diagnosed with kidney disease?*
Have you been diagnosed with Type 2 Diabetes?*
Have you been diagnosed with prediabetes?
Are you a cancer survivor?
If yes, are you currently undergoing treatment for cancer (chemotherapy or radiation)?
Are you caregiver for anyone suffering from cancer?
Please download the Media Consent Form, sign and scan (or take a photo) and email the consent form to lifestylechangeprograms@uthct.edu