YMCA: Diabetes Prevention Program Intake and Qualification

If you need assistance completing this form, please contact us at 408-351-6440 or ymcadpp@ymcasv.org.

Si necesita ayuda para completar este formulario, comuníquese con nosotros al 408-351-6440 o ymcadpp@ymcasv.org.

Have you been previously diagnosed with type 1 or type 2 diabetes?

Have you been previously diagnosed with type 1 or type 2 diabetes? Yes No
Have you been diagnosed with end-stage renal disease?

Have you been diagnosed with end-stage renal disease? Yes No
Participant Details

*required information to complete intake
Today's Date Today's Date / MM / DD YYYY
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Sex at Birth

Sex at Birth Male Female Prefer not to answer
Gender

Gender Man Woman Transgender, non-binary, or another gender Prefer not to answer
Email
Preferred Phone Number Preferred Phone Number - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Education
Language
Ethnicity and Race
Ethnicity and Race Additional Details

Race and Ethnicity Additional Details - Appendix

American Indian or Alaska Native: Includes all individuals who identify with any of the original peoples of North, Central, and South America. It includes people who identify as American Indian or Alaska Native and groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, llingit, etc.
Option to provide additional details, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, llingit, etc.

Asian or Asian American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in East Asia, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.
Option to provide additional details, for example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, Cambodian, Pakistani, Hmong, etc.

Black or African American: Includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the Black racial groups of sub-Saharan Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, Bahamian, etc.
Option to provide additional details, for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, Ghanaian, South African, Barbadian, etc.

Hispanic or Latino: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Mexico, Puerto Rico, Cuba, Central and South American, and other Spanish cultures.
Examples of these groups include, but are not limited to, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, and Colombian. The category also includes groups such as Guatemalan, Honduran, Spaniard, Ecuadorian, Peruvian, Venezuelan, etc.
Option to provide additional details, for example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc.

Middle Eastern or North African: Includes all individuals who identify with one or more nationalities or ethnic groups originating in the Middle East or North Africa. Examples of these groups include, but are not limited to, Lebanese, Iranian, Egyptian, Syrian, Moroccan, and Israeli. The category also includes groups such as Algerian, Iraqi, Kurdish, Tunisian, Chaldean, Assyrian, etc.
Option to provide additional details, for example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, Algerian, Iraqi, Kurdish, etc.

Native Hawaiian or Pacific Islander: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.
Option to provide additional details, for example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, Palauan, Chuukese, Tahitian, etc.

White: Includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Polish, and French. The category also includes groups such as Scottish, Norwegian, Dutch, Slavic, Cajun, Roma, etc.
Option to provide additional details, for example, German, Irish, English, Italian, Polish, French, Scottish, Norwegian, Dutch, etc.
Did a Health Care Professional ask you to enroll?
If you answered yes, which type?

If you answered yes, which type? Doctor/Doctor's Office Pharmacist Other Health Care Professional Other Other
Motivation to Join the Program
Disability / Difficulties Screener
1. Are you deaf or have serious difficulty hearing?

1. Are you deaf or have serious difficulty hearing? No Yes Prefer not to answer
2. Are you blind or have serious difficulty seeing, even w/glasses?

2. Are you blind or have serious difficulty seeing, even w/glasses? No Yes Prefer not to answer
3. Because of a physical, mental or emotional condition, do you have serious difficulty concentrating, remembering or making decisions?

3. Because of a physical, mental or emotional condition, do you have serious difficulty concentrating, remembering or making decisions? No Yes Prefer not to answer
4. Do you have serious difficulty walking or climbing stairs?

4. Do you have serious difficulty walking or climbing stairs? No Yes Prefer not to answer
5. Do you have difficulty dressing or bathing?

5. Do you have difficulty dressing or bathing? No Yes Prefer not to answer
6. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

6. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? No Yes Prefer not to answer
Name of Referring Clinic or Healthcare Provider
Employer Name
Current YMCA Member

Current YMCA Member Yes No
Most convenient YMCA Branch location for you?

Most convenient YMCA Branch location for you? Central YMCA, 1717 The Alameda, San Jose East Valley Family YMCA, 1975 South White Rd, San Jose El Camino YMCA, 2400 Grant Rd, Mountain View Lewis & Joan Platt East Palo Alto Family YMCA, 550 Bell St, East Palo Alto Mt. Madonna YMCA, 171 W. Edmundson Ave, Morgan Hill Northwest YMCA, 20803 Alves Dr, Cupertino Palo Alto Family YMCA, 3412 Ross Rd, Palo Alto Sequoia YMCA, 1445 Hudson St, Redwood City South Valley Family YMCA, 5632 Santa Teresa Blvd, San Jose Southwest YMCA, 13500 Quito Rd, Saratoga
Program Payment

The YMCA's Diabetes Prevention Program may be a covered benefit if you are a member of Valley Health Plan, Santa Clara Family Health Plan, or Medicare. Verification of benefits is required before enrollment.
Insurance Information

Insurance Information Medicare Medi-cal Health Plan of San Mateo Santa Clara Family Health Plan Valley Health Plan No Insurance Other Health Insurance Plan (enter insurer name below)
Insurance ID Number
My income meets federal poverty guidelines.

My income meets federal poverty guidelines. Yes No Decline to answer
Participant Qualification

For program participation, BMI ≥ 25 is required; Asian individual(s) BMI ≥ 23.
Height
Feet
Inches
Weight
BMI (if known)
Blood Value/Diagnosis

Blood values must be within the last year. Note: An individual with a blood value in the normal range cannot be enrolled in the program, even if he or she meets at-risk qualifications (based on risk test below). Blood values are more accurate than risk scores for diabetes risk determination. If available, please enter values and date of test below. If previously diagnosed with gestational diabetes (GDM), indicate approximate date during pregnancy.
Date of most recent test Date of most recent test / MM / DD YYYY
A1c
Fasting plasma glucose
2 hour plasma glucose
Date of GDM diagnosis, if applicable Date of GDM diagnosis, if applicable / MM / DD YYYY
ADA/CDC Risk Assessment

The following questions will be used to determine your risk level for developing Type 2 diabetes.
What is your age?

What is your age? Younger than 40 40-49 years 50-59 years 60 years or older
What is your sex?

What is your sex? Male Female
Have you been diagnosed with gestational diabetes during a previous pregnancy?

Have you been diagnosed with gestational diabetes during a previous pregnancy? Yes No N/A
Do you have a mother, father, sister, or brother with diabetes?

Do you have a mother, father, sister, or brother with diabetes? Yes No
Have you ever been diagnosed with high blood pressure?

Have you ever been diagnosed with high blood pressure? Yes No
Are you physically active?

Are you physically active? Yes No
What is your weight category? (see chart below)

What is your weight category? (see chart below) 3 points 2 points 1 point 0 points
Diabetes Prevention Program Scheduling

Classes meet at the same day and time each week for the duration of the year-long program. Please indicate your preferences below.
Class delivery preference

Class delivery preference In-person Virtually (via Zoom) Either
Day/Time preference
Please note the days and times that work best for you to attend the hour-long weekly meetings
Language Preference
Which language do you prefer for class participation? NOTE: Some languages may not yet be available.

Language Preference
Which language do you prefer for class participation? NOTE: Some languages may not yet be available. English Spanish Other (please specify) Other (please specify)
Support:

If your answer is no, the YMCA may be able to provide assistance to those who qualify.
Do you have internet access and a computer, tablet, or smartphone to attend weekly online classes?

YMCA: Diabetes Prevention Program Intake and Qualification

YMCA: Diabetes Prevention Program Intake and Qualification

Participant Details

Disability / Difficulties Screener

Program Payment

Participant Qualification

Height

Blood Value/Diagnosis

ADA/CDC Risk Assessment

Diabetes Prevention Program Scheduling

Support: