Diabetes Prevention and Weight management Program - Qualification
Thank you for your interest in participating in the National Diabetes Prevention Program (NDPP) offered by Palette Care. Please answer a few questions to determine your eligibility. This form merely determines your eligibility, and you are not engaged in the program until you sign up. Your information will not be shared with a third party and the program is completely free to you if you qualify.
Email *
Name *
Phone *
Do you have Medicaid? *
What's your health insurance company? *
Please check 5 sessions you can attend remotely via call or video conference *
To qualify for the free NDPP program, a referral is required from your primary care doctor or nurse. Will you be able to get a referral or give us the authorization to contact them for you? *
Your primary care doctor's name *
Your primary care doctor's phone number *
Which mobile phone do you use? *
Prediabetes Risk Test by CDC and ADA
If you scored 5 or higher, you are at increased risk for having prediabetes and are at high risk for type 2 diabetes. Type 2 diabetes is more common in African Americans, Hispanics/Latinos, and Asian Americans. Higher body weight increases diabetes risk for everyone.
How old are you? *
Gender *
If you are a woman, have you ever been diagnosed with gestational diabetes? *
Do you have a mother, father, sister, or brother with diabetes? *
Have you ever been diagnosed with high blood pressure? *
Are you physically active? *
What is weight category? Please enter your score below *
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A copy of your responses will be emailed to the address you provided.
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