YMCA Diabetes Prevention

^* Field is required.

Enter your name and address First Name:^* Middle Name: Last Name:^* Suffix: Company: Title: Address 1:^* Address 2: City:^* State:^* ZIP:^*

Email^* user@example.com

Date of Birth Primary Phone Number^* (###)###-####

Referral method

BMI & Qualification Criteria Height (ft)^* 5' 8" Weight (lbs)^*

Diabetes risk assessment. Answer yes or no to the following questions?

Are you a women who has had a baby weighing more than 9 pounds at birth?^* Yes No

2. Do you have a parent with diabetes?^* Yes No

3. Do you have siblings with diabetes?^* Yes No

4. Are you younger than 65 years of age, and get little or no physical activity in a typical day?^* Yes No

5. Are you between 45 and 64 years of age?^* Yes No

6. Are you older than 65 years of age?^* Yes No

7. Find your weight on the chart. Do you weigh more than the weight listed for you height?^* Yes No

A1C/Fasting Glucose?

The YMCA of Metropolitan Dallas