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3Rivers FCU Family YMCA Hours
Sun:
11:00 am-4:00 pm
Mon:
6:00 am-8:00 pm
Tue:
6:00 am-8:00 pm
Wed:
6:00 am-8:00 pm
Thu:
6:00 am-8:00 pm
Fri:
6:00 am-8:00 pm
Sat:
6:00 am-4:00 pm
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YMCA of Greater Fort Wayne
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YMCA of Greater Fort Wayne
Diabetes Prevention, Provider Referral
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Diabetes Prevention, Provider Referral
Diabetes Prevention
Prediabetes Provider Referral
First Name
*
Last Name
*
Address
(Indiana Residents Only)
Street Address
Address Line 2
City
*
State
*
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Zip Code
Phone
*
Email
*
Referring Provider
*
Authorization
*
I authorize that patient permission was received prior to submitting this online referral form to the YMCA's Diabetes Prevention Program.
Can they participate?
In order to qualify for the YMCA’s Diabetes Prevention Program, patients must be overweight (BMI > 25)* and at high risk for developing type 2 diabetes or have been diagnosed with prediabetes.
Has the patient been told that they have prediabetes?
*
Yes
No
Have they already been diagnosed?
If the patient has been diagnosed with prediabetes, please fill in the following applicable values.
Fasting Plasma Glucose
(must be 100 - 125 mg/dl)
2-hour
(75 gm glucola)
Random/Casual Blood Glucose
(must be 140 - 199 mg/dl)
A1c
(must be 5.7 - 6.4%)
Are they at risk for developing diabetes?
Please answer 'yes' if the following statements are true.
Their blood pressure is 140/90 or higher, or I have been told they have high blood pressure
Yes
No
They have been told that their cholesterol levels are not normal
Yes
No
They are fairly inactive. They are NOT physically active more than two times a week.
Yes
No
They have or had a parent or sibling with diabetes.
Yes
No
They have been told they have prediabetes
Yes
No
They have had gestational diabetes or gave birth to a baby weighing more than 9 pounds.
Yes
No
They are 45 years of age or older.
Yes
No
Leave this field blank
Submit
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