Prevent T2 Lifestyle Change Program - Orleans Community Health

1. How old are you?*

Less than 40 years (0 points)
40-50 years (1 point)
50-59 years (2 points)
60 years or older (3 points)

2. Are you a man or a woman?*

Man (1 point)
Woman (0 points)

3. If you are a woman, have you ever been diagnosed with gestational diabetes?*

Yes (1 point)
No (0 points)

4. Do you have a mother, father, sister or brother with diabetes?*

Yes (1 point)
No (0 points)

5. Have you ever been diagnosed with high blood pressure?*

Yes (1 point)
No (0 points)

6. Are you physically active?*

Yes (0 points)
No (1 point)

7. What is your weight status?*

0 Point
1 Point
2 Points
3 Points

**Please reference the Weight Chart to determine status.

8. What is your score?

0-4 Points
5+ Points

If you scored 5 or higher you are likely to have prediabetes and are at risk for type 2 diabetes. However, only your doctor can tell for sure if you have type 2 diabetes or prediabetes. Talk to your doctor to see if additional testing is needed.

I'd like to register for the next Prevent T2 Diabetes Program.*

Yes
No

I'd like more information on the Prevent T2 Diabetes Program.*

Yes
No

Name*

First Last

Phone

Address*

Street Address Address Line 2 City State ZIP Code

Email

General Info

Do you have prediabetes?

Do You Have Prediabetes?