AHN Prediabates Risk Test

Are you at risk for Prediabetes?

Access to Healthcare Network (AHN) is offering wellness programs to help you prevent type 2 diabetes and other chronic conditions.

Please complete this short form and we will contact you to get started with the program that will best meet your needs.

How old are you?*

Less 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 a woman?*

Male (1 point)Female (0 points)

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 been diagnosed with high blood pressure?*

Yes (1 point)No (0 points)

Are you physically active?*

Yes (0 points)No (1 point)

On the chart below, find your height and weight range. Then scroll to the bottom of the chart to see the number of points. How many points does the chart say for your height and weight?*

0 points – My weight is lower that what is listed for my height1 point2 point3 point

Your Score

Complete the form below, and we will contact you about our program, which provides participants with a coach and group support to help prevent type 2 diabetes and other chronic conditions.

Name*

First NameLast Name

Phone Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Age

Would you prefer to attend programs in-person or virtually?

In-personVirtuallyEither is fine

Does a day or evening program work best for you?

DaysEveningsEither is fine

What type of insurance do you have?

I don’t have insuranceMedicareMedicaidPrivate insurance

How did you hear about AHN’s wellness programs?

Do you know if you have diabetes?*

I have diabetesI have prediabetesI do not have diabetes or prediabetesI do not know my status