Diabetes Prevention Program Questionnaire

Diabetes Prevention Program Interest
Ready to reclaim your health? Complete this form, and a YMCA representative will contact you to confirm eligibility and registration.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mobile*
Please enter a valid phone number.
Email*
example@example.com
Text Notification Opt-in**
I would like to receive text/SMS communication from the YMCA
* By opting in to Text/SMS updates, you agree to receive periodic text messages from the YMCA of San Diego County including but not limited to YMCA account, membership or program activity as well as any indicated areas of interest. You can expect approximately 2-4 non-transaction related messages per month. There is no obligation, and you can opt out at any time by replying with the word "STOP" to any text message received. Standard message and data rates may apply. Your privacy is important to us; see our privacy policy for how we protect and use your data.
Do you have a mother, father, sister or brother with diabetes? A family history of diabetes could contribute to your risk for type 2 diabetes?*

YesNo
Have you ever been diagnosed with high blood pressure? Having high blood pressure contributes to your overall risk for type 2 diabetes?*

YesNo
How old are you? Your risk for risk type 2 diabetes increases with age. *

Under age 4040-4950-5960+
What race or ethnicity best describes you? People of certain racial and ethnic groups are more likely to develop type 2 diabetes than others.*

White/CaucasianAmerican Indian or Alaskan NativeAsian AmericanBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderOtherPrefer not to say
Are you physically active? Being inactive can increase your risk for type 2 diabetes.*

YesNo
Are you a male or a female? Males are more likely than females to have undiagnosed diabetes; one reason may be that they are less likely to see their doctor regularly. *

MaleFemalePrefer not to say
What is your height and weight? The combination of your weight and height lets us know your Body Mass Index or BMI. People with higher BMIs are at a higher risk.
Lead Source
Select your YMCA location
Lead Event
Should be Empty:

Diabetes Prevention Program Interest