Patient Details

First Name*

Last Name*

Date of Birth*




Race  American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White Hispanic/Latino Not Hispanic/Latino Other

Ethnicity  Hispanic/Latino Not Hispanic/Latino Other

Eligibility Criteria

Height* Weight* BMI*


Please complete only ONE of the values below

A1C (must be 5.7% - 6.7%)

Fasting Plasma Glucose (must be 100 - 125 mg/dL)

2-Hour (75 gm glucola) Plasmas Glucose (must be 140 - 199 mg/dL)

Prediabetes determined by clinical diagnosis of gestational diabetes (GDM) during previous pregnancy  Yes No
Please complete all questions below:

1) Is the individual a woman who has had a baby weighing more than 9 pounds at birth?

2) Does the individual have a parent with diabetes?

3) Does the individual have a brother or sister with diabetes?

4) Does the individual weigh as much or as more than the suggested weight for their height?

5) Is the individual younger than 65 years old and gets little or no activity in a typical day?

6) Is the individual between 45 and 64 years old?

7) Is the individual 65 years old or older?

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