Diabetes Prevention Program Participant Recommendation DPP Participant Recommendation Participant Information First Name Last Name Date of Birth (MM-DD-YYYY) Phone Number * Email Address Gender Male Female Height: Weight: BMI: Lab Values or Diagnosis Provide a value if possible: A1C: (must be 5.7% - 6.7%) Fasting Plasma Glucose: (must be 100 - 125 mg/dL) 2-Hour (75 gm glucola) Plasmas Glucose: (must be 140 - 199 mg/dL) Prediabetes determined by clinical diagnosis of gestational diabetes (GDM) during previous pregnancy: Yes No Health Care Provider Signature Clear Date If you are human, leave this field blank.