Medical Clearance and Referral Form
Montana Diabetes Prevention Program
Patient Information
Name
Date of Birth
/
Month
/
Day
Year
Date
Phone
Primary Insurance
Physician Name
**Medicaid Patients Only** 9 Digit Client ID
Medical Eligibility Criteria
Select all criteria that pertain to the patient
Age and Weight
Age 18 or Over
Overweight or Obese (BMI > 25)
Additional Qualifying Criteria (Select at least one)
High blood pressure
Dyslipidemia
Diagnosis of Pre-Diabetes
Abnormal Glucose
History of Gestational Diabetes
Medical History
Does the patient take medication for any of the following conditions?
High Cholesterol/Triglycerides
Abnormal Glucose
Hypertension
Labs
Value
Date
HDL Cholesterol
LDL Cholesterol
Triglycerides
Fasting Blood Glucose
Blood Pressure
Anthropometrics
Value
Date
Height
Weight
BMI
Diagnosed with arthritis?
Yes
No
Diagnosed with diabetes?
Yes
No
Referring Provider
I have reviewed the medical eligibility information above and wish to refer this patient to the Diabetes Prevention Program on that basis.
Date
/
Month
/
Day
Year
Date
Signature
Printed Name
Preview PDF
Print Form
Submit
Should be Empty: