Dear Federally Qualified Health Clinic administrator,
The patient presenting this online risk test score is at high risk for prediabetes. Please provide this patient with immediate assistance and the soonest possible blood sugar test.
Risk for prediabetes was determined by the Centers for Disease Control and Prevention/American Medical Association risk assessment test at testyourbloodsugar.org. The patient’s answers to this test and overall risk score are provided below. All scores of 9 or higher indicate a high risk of prediabetes.
Please complete the portion below for the patient to submit for eligibility to the National Diabetes Prevention Program. Please keep a copy for the patient chart and give a copy to the patient.
My patient has prediabetes or is at risk for diabetes; check all that apply.
[ ] Fasting plasma glucose = 100 -125 mg/dL OR,
[ ] 2-hour (75 gm glucose) plasma glucose = 140 – 199 mg/dL
[ ] A1C = 5.7 – 6.4 % OR,
[ ] Clinical diagnosis of Gestational Diabetes GDM during a previous pregnancy
I [ ] do [ ] do not recommend that this patient set goals for achieving 5% - 7% weight reduction through changes in diet and gradual increases in moderate physical activity, and participate in a diabetes prevention program.
Patient Name: ____________________________________Phone: (______)_____________
Provider Signature: ______________________________________ Date: _______________
My total score is
Are you a woman who has had a baby weighing more than 9 pounds at birth? (Yes is 1 point)
Do you have a sister or brother with diabetes? (Yes is 1 point)
Do you have a parent with diabetes? (Yes is 1 point)
Are you younger than 65 years of age and get little or no exercise in a typical day? (Yes is 5 point)
Are you between 45 and 64 years of age? (Yes is 5 point)
Are you 65 years of age or older? (Yes is 5 point)
Find your height on the chart. Do you weigh as much as or more than the weight listed for your height? (Yes is 5 point)
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