More info on Diabetes Prevention
Thank you for your interest in the YMCA Diabetes Prevention Program. Please fill out the information below and Tracie Heavner, Diabetes Prevention Program Director, will contact you within the next 3 business days.
To find out more about if you are at risk for diabetes please take the test below to help Tracie know more about your risk factors.
* Required
Firstname
*
Your answer
Lastname
*
Your answer
Phone Number
*
Your answer
E-mail Address
Your answer
Are you a woman who has had a baby weighing more than 9 pounds at birth?
yes
no
Clear selection
Do you have a parent with diabetes?
yes
no
Clear selection
Do you have a brother or sister with diabetes?
yes
no
Clear selection
Are you younger than 65 years of age and get little or no physical activity in a typical day?
yes
no
Clear selection
Are you between 45 and 64 years of age?
yes
no
Clear selection
Are you 65 years of age or older?
yes
no
Clear selection
Find your height on the below chart. Do you weigh as much as or more than the weight listed for your height?
4'10" - 129lbs; 4'11" - 133lbs; 5'0" - 138lbs; 5'1" - 143lbs; 5'2" - 147lbs; 5'3" - 152lbs; 5'4" - 157lbs; 5'5" - 162lbs; 5'6" - 167lbs; 5'7" - 172lbs; 5'8" - 177lbs; 5'9" - 182lbs; 5'10" - 188lbs; 5'11" - 193lbs; 6'0" - 199lbs; 6'1" - 204lbs; 6'2" - 210lbs; 6'3" - 216lbs; 6'4" - 221lbs
yes
no
Clear selection
Are you a YMCA member?
yes
no
Clear selection
Submit
Never submit passwords through Google Forms.
This form was created inside of YMCA of Greensboro Inc..
Report Abuse
Forms
