Rye YMCA Diabetes Prevention Program Checklist

YMCA's Diabetes Prevention Program Checklist
In order to qualify for the YMCA’s Diabetes Prevention Program, you must be overweight with a Body Mass Index (BMI) of 25 or greater and at high risk for developing type 2 diabetes or have been diagnosed with prediabetes. Not sure what your BMI is? Click here to calculate your BMI. Please answer the questions below to determine if you are at risk for developing diabetes.
DO YOU MEET THE PROGRAM REQUIREMENTS? Please check each box that is true.

I am at least 18 years oldI am overweight (BMI is greater than or equal to 25)I have been diagnosed with prediabetes by a healthcare providerI am a woman who has given birth to a baby weighing more than 9 pounds at birthI have a parent with diabetesI have a brother or sister with diabetesI am younger than 65 years of age and get little or no physical activity in a typical dayI am between 45 and 64 years of ageI am 65 years of age or older
DO YOU HAVE ONE OF THE FOLLOWING LAB VALUES OR DIAGNOSIS? Please check each box that is true.

A1c (must be 5.7 - 6.4%)2-hour (75 gm glucola) Plasma Glucose (must be 140 – 199 mg/dl)Fasting Plasma Glucose: (must be 100 - 125 mg/dL)I do not know my lab valuesI had a clinical diagnosis of Gestational Diabetes (GDM) during a previous pregnancy
If you checked a box above, enter value.
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Height and Weight

HeightWeight
Race/Ethnicity

American Indian or Alaska NativeAsianNative American or Other Pacific IslanderBlack or African AmericanHispanic/Latino of any raceWhite
Is your employer/insurer paying any portion of the fee for you to participate in the YMCA's Diabetes Prevention Program?*

YesNo
HOW DID YOU HEAR ABOUT THE YMCA"S DIABETES PREVENTION PROGRAM? Please check the box that applies.

YMCA brochure/flyerDoctor/PhysicianDiabetes EducatorDietician/NutritionistPharmacistScreening/Testing Event or Health FairFamily/Friend or Word of MouthEmployerInsurance CompanyMediaStaff MemberOther
For more information or questions, contact Heidy Barros, Community Health Coordinator, at 914-967-6363, ext. 114
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YMCA's Diabetes Prevention Program Checklist

For more information or questions, contact Heidy Barros, Community Health Coordinator, at 914-967-6363, ext. 114