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PreventT2 Enrollment Form









Gender:

      

Please answer the following questions below:

Are you a woman who has had a baby weighing more than 9 pounds?

                                        

Do you have a sister or brother with diabetes?

              
 

Do you have a parent with diabetes?

                    

Is your BMI higher than 24 or higher than 22 if Asian?
BMI Calculator

                    

Are you younger than 65 years of age and get little or no exercise in a day?

                    

Are you between 45 and 65 years of age?

                    

Are you 65 years of age or older?

                    

Have you completed your biometric health screening or annual physical in the last year?

                    

In the past year, have you had a fasting glucose of 100 to 125 mg/dl?

                    

Have you been clinically diagnosed with gestational diabetes?

                    

Have you had an A1c of 5.7 to 6.4 but have not had a diagnosis of Type II Diabetes?