If you scored 5 or higher: You're likely to have prediabetes are at high risk for type 2 diabetes. However, only your doctor can tell for sure if you do have type 2 diabetes or prediabetes (a condition that precedes type 2 diabetes in which blood glucose levels are higher than normal Talk to your doctor to see if additional testing is needed.
Type 2 diabetes is more common in African Americans, Hispanic/Latinos, American Indians, Asian Americans and Pacific Islanders.
Higher body weights increase diabetes risk for everyone. Asian Americans are at increased diabetes risk at lower body weights than the rest of the general public (about 15 pounds lower).
LOWER YOUR RISKHere's the good news: it is possible with small steps to reverse prediabetes - and these measures can help you live a longer and healthier life.
If you are at high risk, the best thing to do is contact your doctor to see if additional testing is needed.
Visit DolHavePrediabetes.org for more information on how to make small lifestyle changes to help lower your risk.
RISK TEST COURTESY OF AMERICAN DIABETES ASSOCIATION.
The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.
You answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPATION
PARTICIPANT DECLARATIONIf you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.
I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.
You answered YES to one or more of the questions above. Please STOP filling out the form and see one of the 3 WINS Staff Members. After consulting with our staff, you can look at the next questions to see what your physician might ask you relative to exercise.
Delay becoming more active if:
You have a temporary illness such as a cold or fever; it is best to wait until you feel better.You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a qualified exercise professional before continuing with any physical activity program.
You answered NO to all of the FOLLOW-UP questions about your medical condition, you are ready to become more physically active - sign the PARTICIPATION DECLARATION below:
You answered YES to one or more of the follow-up questions about your medical condition:
You should seek further information before becoming more physically active or engaging in a fitness appraisal. You should complete the specially designed online screening and exercise recommendations program – the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.
You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted.
The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire, consult your doctor prior to physical activity.
I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for records. In these instances, it will maintain confidentiality of the same, complying with applicable law.
For more information, please contact
Citations for PAR-Q+
Warburton DER, Jamnik VK, Bredin SSD, and Gledhill N on behalf of the PAR-Q+ Collaboration. The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and Electronic Physical Activity Readiness Medical Examination (ePARmed-X+). Health & Fitness Journal of Canada 4(2):3-23, 2011.
The PAR-Q+ was created using the evidence-based AGREE process (1) by the PAR-Q+ Collaboration chaired by Dr. Darren E. R. Warburton with Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Donald C. McKenzie (2). Production of this document has been made possible through the financial contributions from the Public Health Agency of Canada and the BC Ministry of Health Services. The view expressed herein do not necessarily represent the views of the Public Health Agency of Canada or the BC Ministry of Health Services.
Community-Based Diabetes Prevention Program
During the period of time that Los Angeles County Department of Public Health is providing guidelines for Covid-19, 3 WINS Fitness will be following those guidelines. In an abundance of caution, our instructors will be wearing masks to cover their mouth and nose while instructing. All sessions will occur outdoors. In the event of poor weather, class will be cancelled as we will not conduct indoor sessions. We will be encouraging participants to spread themselves by 6 feet and we will be more non- verbally demonstrative with our exercise instruction. We will work with the parks to have hand sanitation supplies available and for the foreseeable future, we will be going equipment less. We encourage you to bring your own mats for ground exercises and bring your own water to prevent dehydration.
Your participation in face-to-face research/exercise may increase your risk of exposure to the virus that causes COVID-19 which can cause severe illness, hospitalization and death. Symptoms of COVID-19 include, but are not limited to, a new onset of a cough, sore throat, shortness of breath, respiratory distress, diarrhea, or an unusual rash. They may also include a fever that is at or over 100.4 degrees Fahrenheit. If you experience any of these symptoms, please seek medical advice. http://www.publichealth.lacounty.gov/chs/SPA2/ provides community health services information.
You are being asked to participate in a research study. Participation in this study is completely voluntary. Please read the information below and ask questions about anything that you do not understand before deciding if you want to participate. Steven Loy will be able to answer your questions
Steven Loy, Ph. D. Kinesiology18111 Nordhoff St.Northridge, CA 91330-8287(818) email@example.com
The research team will include faculty from California State University, Northridge. They include Drs. Lisa Chaudhari, Suzanne Spear, and Jimmy Xie.
What is the purpose of this study?The purpose of this study is determine whether a free community-based diabetes prevention program can successfully yield 5%-7% weight loss in adults who are pre-diabetic and improve the health and fitness of all participants including those not identified as pre-diabetic.
Who may participate?You are eligible to participate in this study if you are an adult aged 18 years of age and over and have completed the Health Screening form. ANSWERING YES TO ANY QUESTIONS IN THE PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (2021 PAR-Q+) WILL DISQUALIFY YOU FROM CONTINUING. YOU WILL BE ASKED TO COMPLETE PAGES 2-4 AND BRING THE COPY TO YOUR MEDICAL DOCTOR ALONG WITH THE 3 WINS FITNESS CLEARANCE FORM. YOU WILL BE ALLOWED TO PARTICIPATE WHEN THE MEDICAL CLEARANCE FORM IS RETURNED WITH YOUR DOCTOR’S SIGNATURE.
Related: If you have experienced any adverse event such as broken bones, stroke, heart attack, (Questions 1 and 6 on Par-Q+) or an event that has resulted in hospitalization you will require a signed clearance form by your primary physician before engagement in the program is permitted.
How much of your time is expected?This study will involve approximately 4 hours a week and it will be ongoing.
What does this study involve? A screening session
Ongoing program1. We will be meeting for about 1.3 hours 3 days a week at a designated location. The time will consist of 60 minutes of physical activity and 10-15 minutes of health education at the end of the hour of physical activity.
The physical activity will be conducted in a group setting intended to maintain an elevated heart rate and exercise intensity incorporating aerobic and strength training. Aerobic exercise will be performed at moderate-intensity similar to brisk walking (4 mph/15 minute mile) and progressing to a higher intensity as your fitness improves. Strength training will include the use of body weight or your own weighted backpack exercises with 5-10 exercises for each major muscle group (including upper body, lower body, and core). You will participate in a total body workout that includes modifications specific to your ability.
Following the physical activity portion, we will have a voluntary10-15 minutes of health education including discussion topics revolving around basic nutritional guidelines, physical activity strategies, and behavioral self-management skills. These guidelines will be given to you as an aid to help you reach your main goal of losing 1-2 pounds of weight per week if desired.
What are the risks and discomforts of this program?The risk for you to participate in this program is minimal. The possible risks and/or discomforts you might experience are fatigue, boredom, dizziness, nausea, heart attack, muscle soreness, strain, sprain, broken bones, and mild dehydration. We plan to minimize these risks by including suitable progressions and modifications to you and providing regular exercise water breaks. In the event that you are injured, 9-1-1 will be called and we will remain with you until help arrives. Any costs incurred are your responsibility.
What are possible benefits for participating in this program?The possible benefits you may experience from the procedures described in this program include weight loss, decreased Body Mass Index (BMI) values, a positive shift in well-being, improved fitness, better posture and balance, better self-esteem, stronger muscles and bones, feeling more energetic, relaxation and reduced stress, continued independent living in later life, information retention (revolved around basic nutrition, physical activity and behavioral self-management) and a decreased risk of type 2 diabetes (and other related chronic diseases). Additional benefits of the study include learning about the potential for free, park-based physical activity programs to improve the health of individuals and communities. The information will help 3 WINS Fitness understand what makes the program a good experience for people and encourages them to stick with their exercise program.
What are the alternatives to participation?If you choose to not participate in this 3 WINS Fitness program, there is no other alternative.
What are the costs, reimbursements, and compensation for this program?You will not be paid for your participation in this program and there is no cost to you. You will not be reimbursed for any out-of-pocket expenses, such as parking, transportation, or any medical costs.
WITHDRAWAL OR TERMINATION FROM THE STUDY AND CONSEQUENCESYou are free to withdraw from this study at any time. If you decide to withdraw from this study you should notify Steven Loy immediately. The research team may also end your participation in this study if you do not follow instructions or if your safety and welfare are at risk. We will inform you immediately if this occurs.
CONFIDENTIALITYYour information will be kept confidential by replacing your name with a code. A list linking the code and your identifiable information (e.g. this form) will be stored in a locked file cabinet in a secure faculty office and only the research team on the first page has access to this cabinet. The de-identified research data will be stored electronically on a computer with password protection in a secure office at all times. Storage locations for identifiable information and de-identifiable research data are both in the Department of Kinesiology at California State University, Northridge and will be kept for at least 3 years from the date of the end of the program.
Data from the interviews will recorded on a secure website maintained at CSUN. The website will be password protected. Only the research team will have access to the dataset. Consent forms and participant contact information will be kept confidential by storing it in a locked file cabinet in the study research office. The interview data will not include your name or any personally identifying information. You will be assigned a unique ID code, which will appear with the information you provide in the interview.
Your separate consent will be required to access any information derived from this research project that personally identifies you, except as specifically required by law. Publications and/or presentations that result from this study will not include identifiable information about you.
What if you have questions?If you have any comments, concerns, or questions regarding the conduct of this research please contact Steven Loy listed on the first page of this form.
Mandated ReportingUnder California law, the researchers are required to report known or reasonably suspected incidents of abuse or neglect of a child, dependent adult or elder, including, but not limited to, physical, sexual, emotional, and financial abuse or neglect. If any researcher has or is given such information in the course of conducting this study, he or she may be required to report it to the authorities.
IF YOU HAVE QUESTIONSIf you have any comments, concerns, or questions regarding the conduct of this research please contact the research team listed on the first page of this form. If you have concerns or complaints about the research study, research team, or questions about your rights as a research participant, please contact the Research and Sponsored Programs office, 18111 Nordhoff Street, California State University, Northridge, Northridge, CA 91330-8232, by phone at (818) 677-2901 or email at firstname.lastname@example.org.
VOLUNTARY PARTICIPATION STATEMENTYou should not endorse this form unless you have read it and been given a copy of it to keep. Participation in this study is voluntary. You may refuse to answer any question or discontinue your involvement at any time without penalty or loss of benefits to which you might otherwise be entitled. Your decision will not affect your relationship with California State University, Northridge. Your endorsement below indicates that you have read the information in this consent form and have had a chance to ask any questions that you have about the study.
The rights below are the rights of every person who is asked to be in a research study. As an experimental subject I have the following rights:
If I have other questions I should ask the researcher or the research assistant, or contact Research and Sponsored Programs, California State University, Northridge, 18111 Nordhoff Street, Northridge, CA 91330-8232, by phone at (818) 677-2901 or by email at email@example.com.