Prediabetes – Could it be you?

96 Million American adults, more than 1 in 3 have prediabetes.
This is a serious health condition where the blood sugar levels are higher than normal.

Demographics

First Name *Required Last Name *Required Date of Birth *Required

This question is important for the Risk Assessment. Please use a real Date of Birth and do not simply use a random date!

Current Weight in pounds *Required Height *Required Gender *Required Preferred Language *Required

Race and Ethnicity *Required (Click all that apply)

	Black or African American
	White or Caucasian
	Asian
	American Indian or Alaskan Native
	Native Hawaiian or Other Pacific Islander
	Unknown
	Refused to Answer

Race and Ethnicity *Required (Click all that apply)

	Hispanic
	Non-Hispanic
	Decline/None/Unknown

Zipcode *Required

Street Address Apt/Unit/Suite/Floor City State County

Contact

Email Address Phone Number *Required