First Name

Last Name

Age

What program are you registering for?---In-Person Sioux Center DPP Class, Starting 9/22/22

Who Referred You?

Phone

Address

Email

BMI > 24 (or BMI > 22 for Asian Americans)---YesNoUnsure

Height (Inches)

Weight (Pounds)

Have you been told by your provider that you have prediabetes, elevated blood sugar, or borderline diabetes?---YesNo

What type of blood tests was performed?---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?---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?