YMCA of Silicon Valley: 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
Email
Preferred Phone Number Preferred Phone Number - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Race
Ethnicity
Education
Referral Method
Name of Referring Clinic or Healthcare Provider
Employer Name
Current YMCA Member

Current YMCA Member Yes No
Program Payment

The YMCA's Diabetes Prevention Program maybe 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 Valley Health Plan Santa Clara Family Health Plan Medicare No Insurance Other Insurance (enter insurer name below)
Insurance ID Number
My income meets federal poverty guidelines.

My income meets federal poverty guidelines. Yes No
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.
A1c
Fasting plasma glucose
2 hour plasma glucose
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. Please select your location, time and language preference below.
Which class location do you prefer?

Which class location do you prefer? 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 VIRTUAL – online Zoom meetings ONLY
Which class time do you prefer?

Which class time do you prefer? Weekday Morning Weekday Noon Weekday Evening Saturday Sunday
Which language do you prefer for class participation? NOTE: Some languages may not yet be available.

Which language do you prefer for class participation? NOTE: Some languages may not yet be available. English Spanish Russian Vietnamese Tagalog Mandarin Other (please specify) Other (please specify)
Which class will you attend?

Which class will you attend? English: weekday morning English: weekday at noon English: weekday evening English: Saturday morning Spanish: Saturdays at 9:00 AM Russian: Wednesdays at 6:30 PM I prefer a different day/time I prefer a different day/time
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?
Internal Notes

YMCA of Silicon Valley: Diabetes Prevention Program Intake and Qualification

YMCA of Silicon Valley: Diabetes Prevention Program Intake and Qualification

Participant Details

Program Payment

Participant Qualification

Height

Blood Value/Diagnosis

ADA/CDC Risk Assessment

Diabetes Prevention Program Scheduling

Support: