Diabetes Prevention Program

1. Patient Full Name^*
Please enter text only.

2. SFHP ID Number^* 11-digit SFHP Patient ID number
Please enter your valid 11-digit MemberID.

3. Body weight at last visit^*
lbs Please enter numeric number only

4. Body height at last visit^*
Feet Please enter numeric number only Inches Please enter numeric number only

5. BMI at last visit^* Must be greater than or equal to 25, or 23 if Asian
Please enter numeric number only

6. Most recent A1c or FPG value^* Value given must be within last 12 months
Please enter numeric number only

7. History of Gestational Diabetes during previous pregnancy?^*

8. Family History (Mother or Father) with type 2 diabetes?^*

9. High Blood Pressure?^*

10. Physically inactive (2 or fewer times per week)?^*

11. Would you like to receive periodic updates on your patient’s progress once enrolled?^*

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