COULD YOU HAVE PREDIABETES?

Prediabetes means your blood glucose (sugar) is higher than normal, but not yet diabetes. Diabetes is a serious disease that can cause heart attack, stroke, blindness, kidney failure, or loss of feet or legs. Type 2 diabetes can be delayed or prevented in people with prediabetes through effective lifestyle programs. Take the first step. Find out your risk for prediabetes.

Please complete the information listed below. A Cabarrus Health Alliance employee will follow up with you to discuss your enrollment in a free Type 2 Diabetes Prevention Class!

 

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* 1. Are you a woman who has had a baby weighing more than 9 pounds at birth?

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* 2. Do you have a sister or brother with diabetes?

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* 3. Do you have a parent with diabetes?

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* 4. Are you younger than 65 years of age and get little or no exercise in a typical day?

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* 5. Are you between 45 and 64 years of age?

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* 6. Are you 65 years of age or older?

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* 7. Weight:

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* 8. Height:

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* 9. Name:

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* 10. Date of birth:

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* 11. Age:

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* 12. Gender:

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* 13. Race/ethnicity (check all that apply):

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* 14. Phone number (include area code):

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* 15. Email:

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* 16. Address:

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* 17. County you reside in:

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* 18. Will you require childcare:

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* 19. How many children would require childcare:

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* 20. How would you get to class:

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* 21. Please check the days AND times you are generally available:

  Morning (7am-12pm) Afternoon (12pm-5pm) Evening (5pm-8pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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