Below is the screening form for the UAB Online Diabetes Program. This form will determine whether you are eligible to move forward. If eligible, you will be directed to complete the online consent form. If you need assistance with completing the screening document, please reach out to our team at 205-975-3270.
Are you 18 years or older?
* must provide value
Yes
No
How old are you?
* must provide value
(in years)
Do you have Type 2 Diabetes?
* must provide value
Yes
No
Are you currently using insulin for diabetes treatment?
* must provide value
Yes
No
Is your current HbA1c level equal to or greater than 7.5%?
* must provide value
Yes
No
Please provide your current HbA1c level.
* must provide value
Are you currently enrolled in any diabetes related intervention? (This includes any study, program, or educational classes).
* must provide value
Yes
No
Do you have any impairment or health problem that limits your ability to walk or run?
* must provide value
Yes
No
Refused
Don't know
Missing
Do you have any impairment or health problem that requires you to use special equipment, such as a brace, a wheelchair, or a hearing aid (excluding eyeglasses or corrective shoes)?
* must provide value
Yes
No
Refused
Don't know
Missing
Because of a health problem, do you have difficulty walking without using any special equipment?
* must provide value
Yes
No
Refused
Don't know
Missing
By yourself and without using any special equipment, how much difficulty do you have walking for a quarter of a mile [that is about 2 or 3 blocks]?
* must provide value
No difficulty
Some difficulty
Much difficulty
Unable to do
Do not do this activity
Refused
Don't know
Missing
By yourself and without using any special equipment, how much difficulty do you have standing up from an armless straight chair?
* must provide value
No difficulty
Some difficulty
Much difficulty
Unable to do
Do not do this activity
Refused
Don't know
Missing
By yourself and without using any special equipment, how much difficulty do you have eating, like holding a fork, cutting food or drinking from a glass?
* must provide value
No difficulty
Some difficulty
Much difficulty
Unable to do
Do not do this activity
Refused
Don't know
Missing
Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?
* must provide value
Yes
No
Refused
Don't know
Missing
Do you experience any cognitive impairment?
* must provide value
Yes
No
Have you had severe, untreated depression within the last 6 months?
* must provide value
Yes
No
Have you had a major cardiac event (like a heart attack or heart surgery) in the past 12 months?
* must provide value
Yes
No
Do you currently have uncontrolled blood pressure?
* must provide value
Yes
No
Do you have an abnormally fast resting heart rate (tachycardia)?
* must provide value
Yes
No
Have you undergone dialysis, kidney transplant, or a kidney surgery in the past 12 months?
* must provide value
Yes
No
Are you presently pregnant or are planning on becoming pregnant in the next 12 months?
* must provide value
Yes
No
Do you experience weakness, numbness, or pain in the feet and hands (Peripheral neuropathy)?
* must provide value
Yes
No
Are you fluent in conversing in English?
* must provide value
Yes
No
Do you have access to a smartphone that can run "apps"?
* must provide value
Yes
No
(examples include Apple or Android phones)
Do you have internet connection capabilities?
* must provide value
Yes
No
What state do you live in?
* must provide value
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
As part of the UAB Online Diabetes Program, you will receive coaching calls for 12 weeks. Would you be available for coaching calls on weekdays from 9:00a to 5:00p CST (Central Standard Time)?
* must provide value
Yes
No
Thank you for completing the study screening form. Based on your answers, you are eligible to participate in the online diabetes management program. Please select "Yes" to continue to complete the online consent form. If you are not interested in participating, please select "No."
* must provide value
Yes
No
Please provide an email address that you regularly check so we may send you updates regarding your participation in the UAB Online Diabetes Program.
* must provide value
Not every opportunity is right for everyone, but we have more resources and programs to help you at NCHPAD - the National Center on Health, Physical Activity and Disability. NCHPAD is a resource center for you! We connect people with disabilities and providers to health promotion, wellness and disability information, programs, and services. Connect with an Inclusion Specialist to learn more! Visit nchpad.org, call 1-800-900-8086 or email email@nchpad.org.
Storage of Information for Recruitment Database With your permission, the research team will store your demographics and contact information in a recruitment database where we can contact you regarding future research opportunities that you might be interested in. The information will include your name, phone number, mailing address, email address, date of birth, gender, race/ethnicity, and primary/secondary diagnosis. You do not have to agree to allow your information to be stored in our recruitment database in order to be part of this study. Please select your choice below:
* must provide value
I agree to have my information to be stored in the recruitment database and be contacted for future research opportunities.
I do not agree to have my information to be stored in the recruitment database and do not want to be contacted for future research opportunities.
Please provide your email address.
* must provide value
Please provide your phone number (preferably cell/mobile phone).
* must provide value
Submit
Save & Return Later
Working...