DIABETES PREVENTION PROGRAM ENROLLMENT FORM

Risk Assessment Form

YMCA Diabetes Prevention Program
Please select the choice that best pertains to you*

I have been diagnosed with prediabetesI have not been diagnosed but have a risk for type II diabetesI have been diagnosed with type II diabetesI have been diagnosed with gestational diabetes in the pastI have not been diagnosed but am interested in the program
Registration Date

MonthDayYear
Date
PARTICIPANT DETAILS
Name

First NameLast Name
Phone Number (Include area code)
Please enter a valid phone number.
Email
example@example.com
Program Qualification Health Questionnaire
Height in Inches (ex: 5'6" = 66)
Weight in Pounds (ex: 170)
Review the chart above to identify your BMI based on your current height and weight and select the BMI Category that you fall into below:

UnderweightNormalOverweightObese
BMI Calculated
MEETS BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Check for the criteria below first. If this information in unavailable, proceed to “Meets CDC At-Risk Qualifications” section, below
A1C (Must be 5.7%-6.4%)
Fasting Plasma Glucose (must be 100-125mg/dL)
2-Hour (75 gm glucola) Plasma Glucose (must be 140-199mg/dL)
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy

YesNoN/A
Meets ADA/CDC At-Risk Qualifications

Complete the questions below based on the candidate's response only if above qualifying information is unavailable
Add the number of points listed
How old are you?
If you are a woman, have you ever been diagnosed with gestational diabetes?
Do you have a mother, father, sister, or brother with diabetes?
Have you ever been diagnosed with high blood pressure?
Are you physically active?
What is your Weight POINT Category bosed on the weigh chart below (see bottom of chart)
Total Risk Score (score must be 5 or greater to qualify for enrollment in "At Risk" category)
Enrollment Questions
Sex

MaleFemaleOther
Contact Preference

PhoneEmail
Date of Birth (must be 18 years of age or older for this program)

MonthDayYear
Date
Address Street
City
State
Zip Code
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoPrefer not to answer
Race

American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or pacific IslanderWhite or CaucasianPrefer not to answerOther
Education

Less than High SchoolHigh School Diploma or GEDAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate DegreeProfessional Degree (MD,JD, DDS, etc)Prefer not to answer
Payor Type

Self-paySelf and/or Financial AidDirect PayorOther
Do you have Medicare Part B?

YesNo
Payor or Funder name (if applicable)
Referral Method

Health Care ProviderMedia/MarketingScreening/Testing Event or Health FairStaff MemberFriend/Family/Word of MouthEmployer or Insurance CompanyPast Program ParticipantOther
Employer name (if selected)
Should be Empty:

Risk Assessment Form

PARTICIPANT DETAILS

Program Qualification Health Questionnaire

MEETS BLOOD VALUE/DIAGNOSIS QUALIFICATIONS

Meets ADA/CDC At-Risk Qualifications

Enrollment Questions