BEATStroke Sign-up Form

What clinic or community program are you a part of?

If your clinic/health system or community is not one of the ones listed above, unfortunately, BEATStroke is not available to you at this time. We are working on expanding the program, so please check back at a later date. You are also welcome to e-mail us (info@beatT2diabetes.com) and we will add you to our wait list and let you know if the program becomes available in your area.

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Name

Preferred Name (if different from above)

Address

Mobile Phone Number

Email

Name of Clinic/Enrollment Site

Birthday

Race

Ethnicity

Hispanic or Latino Not Hispanic or Latino

Gender

Male Female Other

Type of Insurance

No Insurance Medicaid Medicare Commercial Insurance (through workplace or individual policy)

What is the highest degree or level of school you have completed?

Height

Feet

Inches

Weight

Pounds

Recent Blood Pressure

Systolic (Top Number)

Diastolic (Bottom Number)

The following questions will help customize your text message advice.

Which of the following stroke and heart disease risk factors do you have? (Check all that apply)

Do you have physical disabilities that prevent you from being able to walk up a flight of stairs or from being able to walk a block on flat ground without assistance?

Yes No

Do you drink regular (non-diet) soda?

Yes No

Do you do the grocery shopping for your family?

Yes No

If you have Type 2 diabetes, do you use insulin to treat your diabetes?

Yes No

Within the past 12 months, did you worry that your food would run out before you got money to buy more?

Yes No

How confident are you that you know how to eat to minimize your risk of stroke and heart disease?

Not Confident Somewhat Confident Very Confident

BEATStroke messages occasionally include images as well as text. If you would prefer to opt out of images and receive only text-based messages please check below.

Text Only

The following questions will help set up optional customized reminders. The timing and frequency of these reminders can be changed at any time by reply text or by contacting us by phone or email.

Would you like to set up text message reminders to exercise?

Yes No

Which days of the week would you like to receive the text message reminder to exercise?

What time of day would you like to receive the reminder to exercise?

Would you like to set up text message reminders to take your medications?

Yes No

Please enter what time of day you would like to receive the reminders to take your medication. You can enter up to 3 times a day.

Medication Reminder #1

Medication Reminder #2

Medication Reminder #3

If you have high blood pressure, would you like to set up text message reminders to check your blood pressure?

Yes No

Which days of the week would you like to receive the text message reminders to check your blood pressure?

Please enter what time(s) of day you would like to receive the reminders to check your blood pressure. You can enter up to 2 times a day.

Blood pressure Reminder #1

Blood Pressure Reminder #2

If you have Type 2 diabetes, would you like to set up text message reminders to check your blood sugars?

Yes No

Please enter what time of day you would like to receive the reminders to check your blood sugar. You can enter up to 4 times a day.

Blood Sugar Reminder #1

Blood Sugar Reminder #2

Blood Sugar Reminder #3

Blood Sugar Reminder #4

Optional Motivational Messages: You can choose to receive either general motivational/inspirational messages pulled from a message bank or design your own personalized motivational message that has special meaning for you. Personalized messages can take many forms (reminders of who or what you are getting healthy for, inspirational quotes, Bible verses, etc.).

Personalized Motivational Message

General Motivational/Inspirational Messages

Frequency

Daily Weekly Monthly other: ‎

Is there a specific day of the week/month or time of day that you would like to receive the motivational messages?

Terms of Service

I accept the Terms of Service

Copy of Terms of Service

I have had an opportunity to review the Notice of Privacy Practices

Terms of Service

I agree to receive BEATStroke text messages from BEATDiabetes. I understand that standard text and data rates may apply and that I can discontinue the texts at any point by texting STOP in reply or by contacting BEATDiabetes by phone (434-234-7676) or e-mail (info@beatT2diabetes.com).

Terms of Service

I understand that BEATStroke does not provide personalized medical advice or replace my regular medical care. I will refer any and all questions regarding my medications, blood pressure, blood sugars, etc. to my personal health care team.

Copy of Terms of Service

I understand that the Virginia Department of Health and my clinic/enrollment site may have access to information that is collected, but that any shared information will be de-identified (not associated with my name or other identifying information).

Electronic signature

Clear

Date