Diabetes Prevention
Prediabetes Provider Referral
Address
(Indiana Residents Only)
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.
Have they already been diagnosed?
If the patient has been diagnosed with prediabetes, please fill in the following applicable values.
(must be 100 - 125 mg/dl)
(75 gm glucola)
(must be 140 - 199 mg/dl)
(must be 5.7 - 6.4%)
Are they at risk for developing diabetes?
Please answer 'yes' if the following statements are true.
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