New Mexico Department of Health
Diabetes Prevention and Control Program
National Diabetes Prevention Program Intake Form
Name_____________________________ Date:
Gender: M or F Age: Height:
Mailing Address___________________________________
Phone #____________ Email: ______________________
Medical Provider___________________________________
Prediabetes Determination
diagnosed by FPG
diagnosed by 2-hour OGTT
diagnosed by A1c
determined by clinical diagnosis of GDM during previous pregnancy
determined using the CDC Prediabetes Screening Test
Race/Ethnicity
Hispano or Latino
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Individual Goals
What are your goals for this program? __________________________________________________________________________________________________________________
Why is this important to you? __________________________________________________________________________________________________________________
Readiness
Check the statement that best describes where you are today with your physical activity and healthy eating goal:
I am thinking about it
I have started doing it
It is a regular part of my life
Possible barriers __________________________________________________________________________________________________________________
Health Goals: The Lifestyle Balance Program goals include a 7% weight loss and the accumulation of 150 minutes of physical activity per week. Some of the ways we will accomplish these goals include:
1. Recording everything we eat and drink
2. Recording exercise minutes
3. Measuring food portions
4. Recording the number of fat grams in our food
5. Recording our weight
6. Planning and shopping for healthy food choices
7. Making physical activity a priority in our lives
Willingness
Check the statement that best describes how willing you are to do the above activities on a regular basis.
I am willing to try to do all the activities
I am willing to try to do some of the activities
I am not willing to do those things
Participant’s Signature__________________________________
Lifestyle Coach’s Signature______________________________