Diabetes Prevention Program Intake Form

DPP - Intake

Participant Details

Step 2: Body Mass Index & Qualification Criteria

For program participation, BMI equal to or more than 25. Asian individuals - equal to or more than 22.

Please answer only ONE of the following qualification sets when submitting this form:

Qualification Set #1: Meets Blood Value/Diagnosis Qualification:

Please complete only ONE the values below.

(must be 5.7% - 6.4%)
(must be 100 - 125 mg/dL)
(must be 140 - 199 mg/dL)
Qualification Set #2: Meets At-Risk Qualification:

Please complete all questions below.

(score must be 9 or greater to qualify for enrollment in 'At-Risk' category)
Note: An individual with a blood value in the normal range cannot be enrolled in the program, even if he or she meets at-risk qualifications. Blood values are more accurate than risk scores for diabetes risk determination.

Step 3: Contact Information & Referral Source