Diabetes Prevention Program Risk Assessment Form

The National Diabetes Prevention Program is a Centers for Disease Control and Prevention (CDC) recognized lifestyle program that can help people with pre-diabetes cut their risk of developing type 2 diabetes in half and improve overall health. Eligibility for the program is based on a pre-diabetes risk assessment.


Please fill out the information below to help us determine your eligibility for the program. You will receive an email with more information once this form has been reviewed.

Phone

Provide weight in pounds

ex: 5'7''

Gender*
Which of the following class date/time are you interested in?*
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?*
Do you require any special accommodations to fully participate in a Diabetes Prevention Class?*

ex: large print handouts

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