Diabetes Prevention Program Intake Form

Gathers the health and contact information needed to enroll someone in a diabetes prevention program.

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In the Claude connectors directory

Name

First Name

Last Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone number

Email

Date of birth

Gender

Ethnicity

Race

Height

Starting weight

Enrollment motivation

How you heard about the program

Payer source

Education level

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