BEATStroke Sign-Up Form
01
Eligibility
02
Enrollment Form
What clinic or community program are you a part of?
Centra Community Paramedicine Program
Riverside Stroke Center
Sheltering Arms Institute
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.
Page Break
Name
Preferred Name (if different from above)
Address
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
St Kitts & Nevis
St Lucia
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Other
Mobile Phone Number
Email
Name of Clinic/Enrollment Site
Birthday
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
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?
Less than high school
High school
Associate degree
Bachelor degree
Graduate degree
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)
High blood pressure
High cholesterol
Prediabetes
Type 2 diabetes
Current cigarette smoker
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
On how many of the last SEVEN DAYS did you follow a healthy eating plan?
0
1
2
3
4
5
6
7
NA
On how many of the last SEVEN DAYS did you participate in at least 30 minutes of physical activity? (Total minutes of continuous activity, including walking.)
0
1
2
3
4
5
6
7
NA
On how many of the last SEVEN DAYS did you take your medication as directed?
0
1
2
3
4
5
6
7
NA
On how many of the last SEVEN DAYS did you monitor your blood pressure?
0
1
2
3
4
5
6
7
NA
On how many of the last SEVEN DAYS did you check your blood sugar the number of times recommended?
0
1
2
3
4
5
6
7
NA
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?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What time of day would you like to receive the reminder to exercise?
AM
PM
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
AM
PM
Medication Reminder #2
AM
PM
Medication Reminder #3
AM
PM
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?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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
AM
PM
Blood Pressure Reminder #2
AM
PM
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
AM
PM
Blood Sugar Reminder #2
AM
PM
Blood Sugar Reminder #3
AM
PM
Blood Sugar Reminder #4
AM
PM
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
SUBMIT FORM
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