First Name Last Name Age What program are you registering for?—Please choose an option—In-Person Sioux Center DPP Class, Starting 9/22/22 Who Referred You? Phone Address Email BMI > 24 (or BMI > 22 for Asian Americans)—Please choose an option—YesNoUnsure Height (Inches) Weight (Pounds) Have you been told by your provider that you have prediabetes, elevated blood sugar, or borderline diabetes?—Please choose an option—YesNo What type of blood tests was performed?—Please choose an option—Finger prickFasting glucoseHemoglobin A1COral glucose tolerance testDon't know/don't remember Have you ever been told that you had gestational diabetes mellitus (GDM) during pregnancy?—Please choose an option—YesNo Risk score qualification (hold Ctrl button and click all that apply)Are you a woman who has had a baby weighing more than 9 lb. at birth?Do you have a sibling with diabetes?Do you have a parent with diabetes?Are you younger than 65 years of age and get little to no exercise in a typical day?Are you between 45-64 years of age?Are you 65 years of age or older?
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