Diabetes Prevention, Provider Referral

First Name *

Last Name *

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.

Has the patient been told that they have prediabetes? *

Yes

No

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%)

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

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