West Cook YMCA Diabetes Prevention Program Referral Form

To qualify, participants must be at least 18 years of age, overweight with a Body Mass Index of >25, or >23 (if Asian American), and have pre-diabetes as verified by a blood test OR qualifying risk assessment.

Participants will not be eligible if they have been diagnosed with diabetes or are pregnant.

This form is HIPAA Compliant.

Patient Name*

First NameLast Name

Patient Phone Number*

Please enter a valid phone number.

Patient Email*

example@example.com

Participant Gender (at birth)*

MaleFemale

Patient Date of Birth*

Date

Participant Height (in)*

Participant Weight (lbs)*

Participant BMI (kg/m2)*

Participant has a qualifying A1c blood value (between 5.7%-6.4%) within the last 12 months*

YesNo

Who requested the A1c blood value test?*

Referring Doctor completing this formAnother Physician

Physician that requested the A1c lab*

PrefixFirst NameLast Name

Date of A1c Value*

Date

Enter A1c blood value*

Please take the following risk assessment.*

	Yes	No
Are you a woman who has given birth to a baby weighing more than 9 pounds?- 1 point
Do you have a parent with diabetes?- 1 point
Do you have a brother or sister with diabetes?- 1 point
Find your height on the chart below. Do you weigh as much or more than the weight listed for your height?- 5 points
Are you younger than 65 years of age and get little or no physical activity in a typical day? -5 points
Are you between 45 and 65 years of age?- 5 points
Are you 65 years of age or older?- 9 points

For each "yes" answer in the risk assessment, add the number of points listed. If the score is 9 or higher, the patient likely qualifies for the program*

I am referring this patient participate in the YMCA's Diabetes Prevention Program.*

Physician Name

I obtained verbal (by phone, in-person, or electronic transmission) patient authorization to release this information to the YMCA.*

Yes

Provider Signature*

Date*

Date