Please answer only ONE of the following qualification sets when submitting this form:
Qualification Set #1: Meets Blood Value/Diagnosis Qualification:
Please complete only ONE the values below.
Qualification Set #2: Meets At-Risk Qualification:
Please complete all questions below.
Note: An individual with a blood value in the normal range cannot be enrolled in the program, even if he or she meets at-risk qualifications. Blood values are more accurate than risk scores for diabetes risk determination.