West Cook YMCA Diabetes Prevention Program Referral Form

To qualify, participants must be at least 18 years of age, overweight with a Body Mass Index of >25, or >23 (if Asian American), and have pre-diabetes as verified by a blood test OR qualifying risk assessment.

Participants will not be eligible if they have been diagnosed with diabetes or are pregnant.

This form is HIPAA Compliant.

Patient Name

First NameLast Name

Patient Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Patient Email

example@example.com

Participant Gender (at birth)

Patient Date of Birth

Date

Participant Height (in)

Participant Weight (lbs)

Participant BMI (kg/m2)

Participant has a qualifying A1c blood value (between 5.7%-6.4%) within the last 12 months

Who requested the A1c blood value test?

Physician that requested the A1c lab

PrefixFirst NameLast Name

Date of A1c Value

Date

Enter A1c blood value

Please take the following risk assessment.

Rows	Yes	No
Are you a woman who has given birth to a baby weighing more than 9 pounds?- 1 point
Do you have a parent with diabetes?- 1 point
Do you have a brother or sister with diabetes?- 1 point
Find your height on the chart below. Do you weigh as much or more than the weight listed for your height?- 5 points
Are you younger than 65 years of age and get little or no physical activity in a typical day? -5 points
Are you between 45 and 65 years of age?- 5 points
Are you 65 years of age or older?- 9 points

For each "yes" answer in the risk assessment, add the number of points listed. If the score is 9 or higher, the patient likely qualifies for the program

I am referring this patient participate in the YMCA's Diabetes Prevention Program.

Physician Name

I obtained verbal (by phone, in-person, or electronic transmission) patient authorization to release this information to the YMCA.

Provider Signature

Date