| YMCA of Greater Fort Wayne

Diabetes Prevention, Provider Referral

Submitted by Anonymous (not verified) on Mon, 01/21/2019 - 11:28am

Diabetes Prevention

Prediabetes Provider Referral

First Name *

Last Name *

Address

(Indiana Residents Only)

Street Address

Address Line 2

City *

State *

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

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

They have been told that their cholesterol levels are not normal

Yes

They are fairly inactive. They are NOT physically active more than two times a week.

Yes

They have or had a parent or sibling with diabetes.

Yes

They have been told they have prediabetes

Yes

They have had gestational diabetes or gave birth to a baby weighing more than 9 pounds.

Yes

They are 45 years of age or older.

Yes

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Diabetes Prevention, Participant Inquiry

Submitted by Anonymous (not verified) on Mon, 01/21/2019 - 11:00am

First Name *

Last Name *

Address

(Indiana Residents Only)

Street Address *

City *

State *

Zip Code *

Phone Number *

Email *

Do you have a mother, father, sister, or brother with diabetes?

Yes

A family history of diabetes could contribute to your risk for type 2 diabetes.

Have you ever been diagnosed with high blood pressure?

Yes

Having high blood pressure contributes to your overall risk for type 2 diabetes.

How old are you?

You are at a higher risk for type 2 diabetes the older you are.

What Race or ethnicity best describes you?

People of certain racial and ethnic groups are more likely to develop type 2 diabetes than others.

Are you physically active?

Yes

Being inactive can increase your risk for type 2 diabetes.

Are you a man or a woman?

Man

Woman

Men are more likely than women to have undiagnosed diabetes; one reason may be that they are less likely to see their doctor regularly.

How tall are you?

The combination of your weight and height lets us know your Body Mass Index or BMI. People with higher BMIs are at a higher risk.

What is your weight?

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Diabetes Prevention Program Risk Assessment

Submitted by Anonymous (not verified) on Mon, 01/21/2019 - 9:54am

Read more about Diabetes Prevention Program Risk Assessment

Obesity Wellness Network

When it comes to losing weight and fighting these diseases, many don’t realize that seemingly difficult behaviors such as eating healthy and exercising regularly can be made easier and attainable through small changes to their everyday lives. There are hundreds of small steps that Americans can incorporate within their busy lifestyles to begin moving themselves and their families toward health.

Diabetes Prevention Healthcare Provider Referral

Diabetes Prevention Program

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Safety Policy

Safety Matters at the Y. As part of our commitment to provide a safe environment for all YMCA members and guests, our staff participate in ongoing training to quickly respond to a crisis situation which threatens the safety of people participating at the YMCA. These preparedness trainings include but are not limited to: