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CDC Prediabetes Screening Test

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!

 
1.Are you a woman who has had a baby weighing more than 9 pounds at birth?
2.Do you have a sister or brother with diabetes?
3.Do you have a parent with diabetes?
4.Are you younger than 65 years of age and get little or no exercise in a typical day?
5.Are you between 45 and 64 years of age?
6.Are you 65 years of age or older?
7.Weight:
8.Height:
9.Name:
10.Date of birth:
11.Age:
12.Gender:
13.Race/ethnicity (check all that apply):
14.Phone number (include area code):
15.Email:
16.Address:
17.County you reside in:
18.Will you require childcare:
19.How many children would require childcare:
20.How would you get to class:
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