Are You at Risk of Prediabetes?

Are You at Risk of Prediabetes?

The Bear River Health Department (BRHD) offers the National Diabetes Prevention Program to help you prevent type 2 diabetes and other chronic conditions. Please complete this short form and we will contact you to get started. Also, please feel free to contact us directly at (435) 792-6510. We would love to hear from you.

How old are you?*

Less than 40 years (0 points)40-49 years (1 point)50-59 years (2 points)60 years or older (3 points)

What was your sex assigned at birth?*

Man (1 point)Woman (0 points)

Were you ever diagnosed with gestational diabetes (or diabetes while pregnant)?*

Yes (1 point)No (0 points)

Do you have a parent or sibling with diabetes?*

Yes (1 point)No (0 points)

Have you been diagnosed with high blood pressure?*

Yes (1 point)No (0 points)

Are you physically active?*

Yes (0 points)No (1 point)

Look at the chart below. Find your height, then your weight range. Then, move to the bottom of the chart to see your points. How many points does this chart say for your height and weight?*

0 points - my weight was lower that what is listed for my height1 point2 points3 points

Your Score:

If you scored 5 or higher:

You’re likely to have prediabetes and are at high risk of developing type 2 diabetes. However, only your doctor can tell you for sure if you have type 2 diabetes or prediabetes (a condition when blood sugars are higher than normal but not yet diabetes). Talk to your doctor to see if additional testing is needed.

If you would like to be contacted about our diabetes prevention program, please enter your contact information below.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email

example@example.com

What type of insurance do you have?

MedicareMedicaidPrivate insuranceI don't have insurance

Age

Would you prefer to attend the program in-person or virtually?

In-personVirtuallyEither is fine

Does a day or night program work best for you?

DaysNightsEither is fine

Do you know if you have diabetes?*

I have diabetesI have prediabetesI do not have diabetes or prediabetesI do not know my status

Click here to receive text messages about health and wellness programs and events from Bear River Health Department

By clicking submit, you agree to receive information about health and wellness programs and events from Bear River Health Department.