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Have you been previously diagnosed with type 1 or type 2 diabetes?
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Have you been diagnosed with end-stage renal disease?
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Participant Details
*required information to complete intake
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Current YMCA Member
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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.
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Insurance Information *
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My income meets federal poverty guidelines. *
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Participant Qualification
For program participation, BMI ≥ 25 is required; Asian individual(s) BMI ≥ 23.
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Height
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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.
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ADA/CDC Risk Assessment
The following questions will be used to determine your risk level for developing Type 2 diabetes.
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What is your age? *
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What is your sex? *
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Have you been diagnosed with gestational diabetes during a previous pregnancy? *
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Do you have a mother, father, sister, or brother with diabetes? *
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Have you ever been diagnosed with high blood pressure? *
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Are you physically active? *
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What is your weight category? (see chart below) *
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Diabetes Prevention Program Scheduling
Classes meet at the same day and time each week. Please select your location, time and language preference below.
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Which class location do you prefer? *
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Which class time do you prefer? *
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Which language do you prefer for class participation? NOTE: Some languages may not yet be available. *
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Which class will you attend?
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Support:
If your answer is no, the YMCA may be able to provide assistance to those who qualify.
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