The YMCA's Diabetes Prevention Program Risk Assessment Form
If you are at high risk of developing type 2 diabetes, the YMCA’s Diabetes Prevention Program can help you make
lifestyle changes that will improve your overall health and well-being and reduce your chances of developing the
disease. Take the first step in controlling your health. Find out your risk for prediabetes.

In order to qualify for the YMCA’s Diabetes Prevention Program, participants must be at least 18 years old,
overweight (BMI ≥ 25)* and at high risk for developing type 2 diabetes or have been diagnosed with prediabetes.

Below is a risk assessment form that helps determine if you qualify for the program. A score of 9 or higher means you may be at risk for prediabetes or diabetes and may qualify for the program. This does NOT mean you have diabetes. You will need a blood test to confirm if you have diabetes.

Contact Karin Speicher at 574-287-9622 for more information.

Once you complete the assessment, a YMCA of Michiana representative will contact you.

Download our privacy practices at: http://michianaymca.org/wp-content/uploads/2017/10/PrivacyPractices-1.pdf

Name *
Your answer
Email Address *
Your answer
Phone Number
Your answer
Do you have one of the following lab values or diagnoses?
If you selected one of the checkboxes above, please provide your lab results:
Your answer
Are you a woman who has given birth to a baby weighing more than 9 pounds?
1 point
Do you have a parent with diabetes?
1 point
Do you have a sibling with diabetes?
1 point
Are you younger than 65 years of age and get little or no physical activity in a typical day?
5 points
Are you between 45 and 64 years of age?
5 points
Are you 65 years old or older?
9 points
Find your height in the image below. Do you weigh as much or more than the weight listed for your height?
5 points
Captionless Image
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