2024 Diabetes Prevention Program assessment

Take this assessment to find out if you qualify for the Diabetes Prevention Program at the Y.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
If you have a recent A1C blood value, please list below. If your percentage is between 5.7%-6.4%, you automatically qualify for this program.

Please take the following risk assessment.*

	0 Points	1 Point	2 Points	3 Points
How old are you? Younger than 40 years (0 Points) 40-49 Years (1 Point) 50-59 Years (2 Points) 60 years or older (3 Points)
Are you a man or woman? Man (1 point) Woman (0 Points)
If you are a woman, have you ever been diagnosed with gestational diabetes Yes (1 Point) No (0 Points)
Do you have a mother, father, sister, or brother with diabetes Yes (1 Point) No (0 Points)
Have you ever been diagnosed with high blood pressure? Yes (1 Point) No (0 Points)
Are you physically active? Yes (0 Points) No (1 Point)
What is your weight category? See chart below

Add the number of points. *
If your score is 5 or higher, you are at increased risk for prediabetes and are at high risk for type 2 diabetes and may qualify for the Diabetes Prevention Program. However, only your doctor can tell for sure if you have type 2 diabetes or prediabetes, a condition in which blood sugar levels are higher than normal but not high enough yet to be diagnosed as type 2 diabetes.

Talk to your doctor to see if additional testing is needed.If you are African American, Hispanic/Latino American, American Indian/Alaska Native, Asian American, or Pacific Islander, you are at higherrisk for prediabetes and type 2 diabetes. Also, if you are Asian American, you are at increased risk for type 2 diabetes at a lower weight (about 15 pounds lower than weights in the 1 Point column). Talk to your doctor to see if you should have your blood sugar tested.
Should be Empty:

Take this assessment to find out if you qualify for the Diabetes Prevention Program at the Y.