Risk Assessment/Enrollment Form
YMCA Diabetes Prevention Program
Please select the choice that best pertains to you
*
I have been diagnosed with prediabetes
I have not been diagnosed but have a risk for type II diabetes
I have been diagnosed with type II diabetes
I have been diagnosed with gestational diabetes in the past
I have not been diagnosed but am interested in the program
Registration Date
-
Month
-
Day
Year
Date
PARTICIPANT DETAILS
Name
First Name
Last 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:
Underweight
Normal
Overweight
Obese
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%)
Date of A1C Measurement if Entered above
-
Month
-
Day
Year
Date
Fasting Plasma Glucose (must be 100-125mg/dL)
Date of Fasting Plasma Glucose Measurement if Entered Above
-
Month
-
Day
Year
Date
2-Hour (75 gm glucola) Plasma Glucose (must be 140-199mg/dL)
Date of 2-Hour Plasma Glucose Measurement if Entered Above
-
Month
-
Day
Year
Date
Prediabetes determined by clinical diagnoses of gestational diabetes during previous pregnancy
Yes
No
N/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?
Please Select
Younger than 40 (0 points)
40-49 (1 point)
50-59 (2 points)
60 and over (3 points)
If you are a woman, have you ever been diagnosed with gestational diabetes?
Please Select
Yes (1 point)
No (0 points)
Do you have a mother, father, sister, or brother with diabetes?
Please Select
Yes (1 point)
No (0 points)
Have you ever been diagnosed with high blood pressure?
Please Select
Yes (1 point)
No (0 points)
Are you physically active?
Please Select
Yes (0 points)
No (1 point)
What is your Weight POINT Category bosed on the weigh chart below (see bottom of chart)
Please Select
1
2
3
Total Risk Score (score must be 5 or greater to qualify for enrollment in "At Risk" category)
Enrollment Questions
Sex
Male
Female
Other
Contact Preference
Phone
Email
Date of Birth (must be 18 years of age or older for this program)
-
Month
-
Day
Year
Date
Address Street
City
State
Zip Code
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Race
American Indian/Alaska Native
Asian
Black or African American
Middle Eastern of North African
Native Hawaiian or pacific Islander
White or Caucasian
Prefer not to answer
Other
Education
Less than High School
High School Diploma or GED
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate Degree
Professional Degree (MD,JD, DDS, etc)
Prefer not to answer
Payor Type
Self-pay
Self and/or Financial Aid
Direct Payor
Other
Payor or Funder name (if applicable)
Do you have Medicare Part B?
Yes
No
Policy ID (if using Medicare Part B to cover program cost)
Group Number (if applicable)
Do you have any difficulties with hearing?
I am deaf or have serious difficulty hearing
I am NOT deaf or DO NOT have serious difficulty hearing
Do you have any difficulties with your vision?
I am blind or have serious difficulty seeing, even when wearing glasses
I am NOT blind or DO NOT have serious difficulty seeing, even when wearing glasses
Do you have any difficulties with the following areas?
I have serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition
I DO NOT have serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition
Do you have any difficulties walking or climbing stairs?
I have serious difficulty walking or climbing stairs
I DO NOT have serious difficulty walking or climbing stairs
Do you have difficulties dressing or bathing?
I have difficulty dressing or bathing
I DO NOT have difficulty dressing or bathing
Do you have difficulties doing errands alone because of a physical, mental, or emotional condition?
I have difficulty doing errands alone because of a physical, mental or emotional condition
I DO NOT have difficulty doing errands alone because of a physical, mental or emotional condition
Who/what motivated you the most to sign up for this program. What was the most influential factor?
Health Care Professional
Blood Test Results
Prediabetes Risk Test
Someone at a Community Based Organization (Church, YMCA, Community Center)
Family or Friends
Current or Past Participant in the Program
Employer
Health Insurance Plan
Media/Marketing
Program Champion
Employer name (if selected)
Did a healthcare professional asked you to join the program, if so which type of provider was it?
Doctor/Doctor's Office
Pharmacist
Other Health Care Professional
No
Submit
Should be Empty: