Program Intake Form printable pdf download

Program Intake Form

NATIONAL DIABETES PREVENTION PROGRAM INTAKE FORM

(Please Print)

Today’s date:

Primary Care Physician:

PARTICIPANT INFORMATION

Last name:

First:

Middle:

Height: (ft., in)

Weight (lbs.)

Birth date:

Age:

Gender:

 F

 M

 American Indian/Alaska Native  Asian  Black or African American  Hispanic or Latino  Native Hawaiian/Pacific Islander

Race/Ethnicity:

 White

Occupation:

Street address:

Cell phone no.:

Home phone no.:

(

)

(

)

P.O. box:

City:

State:

ZIP Code:

Email Address:

Heard about program/referred by (please check all that apply):

 Diabetes Educator

 Dietitian/Nutritionist

 Dr./Physician_____________

 Printed Ad/Poster (newsletter/paper)

 Worksite Wellness Coordinator/Program

 Nurse

 News (radio, online)

 Employer

 Insurance Provider



Dhhs.nh.gov/dphs/cdpc/diabetes/prediabetes.htm

 Hospital

 Screening/Testing Event or Health Fair

 Facebook/Twitter

Family/Friend

Other_______________

PARTICIPANT ELIGIBILITY

(Please Indicate Prediabetes Status/Type 2 Diabetes at Risk Criteria.)



BMI: ≥ 25 (Asian ≥ 22)

 Fasting glucose of

 Plasma glucose measured 2

A1c of 5.7 to 6.4

 Clinically diagnosed GDM

 Positive for prediabetes

100 to 125 mg/dl

hours after a 75 gm glucose load

during a previous pregnancy (may

based on the CDC

of 140 to 199 mg/dl

be self-reported)

Prediabetes Screening Test

PARTICIPANT PAYMENT/COVERAGE

National Diabetes Prevention

 Self-pay

 State Employee/CHERP

Other________________

Program Payment:

Patient Signature

Date

Program Intake Form

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