• West Cook YMCA Healthcare Provider Referral Form

  • To qualify for the Blood Pressure Self-Monitoring Program, participants must be at least 18 years of age, diagnosed with hypertension or currently taking antihypertensive medication, not have experienced a recent cardiac event, not have atrial fibrillation or other arrhythmias, and not be at risk for lymphedema.

     

    To qualify for the Diabetes Prevention Program, 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.

     

    The Weight Loss Program is for adults who are 18 years and older who desire a healthier weight. This program is not intended for individuals with specialized needs due to chronic disease or the onset of chronic disease. 

     

    This form is HIPAA Compliant.

  • Format: (000) 000-0000.
  • Participant Sex (at birth)*
  •  - -
  • I am referring the patient to the Blood Pressure Self-Monitoring Program*
  • I am referring the patient to the Diabetes Prevention Program*
  • I am referring the patient to the Weight Loss Program*
  • Has the patient been diagnosed with hypertension?*
  • Is the patient currently taking antihypertensive medication?*
  • Has the patient had a recent cardiac event in the last 12 months?*
  • Does the patient have atrial fibrillation or other arrhythmias?*
  • Is the patient at risk for lymphedema?*
  •  - -
  • Referring Healthcare Partner Organization*
  • Should be Empty: