COACHSHELLIE TEAM PREVENT
 
 
Are you a member of the Kentucky Employee Health Plan (administered by Anthem)? *
The following questions are required for reporting purposes to the Centers for Disease Control and Prevention (CDC). Only anonymous data will be reported to the CDC. Your name will not be used in connection with the data reported.
Gender: *
Have you ever been diagnosed with prediabetes through a blood test? (Answering no will not disqualify you from the program.) *
Have you ever been diagnosed with gestational diabetes? *
Have any of your siblings or either of your parents been diagnosed with diabetes? *
Are you younger than 65 years of age and get little or no exercise in a typical day? *
What is your ethnicity? *
What is your race? Choose all that apply. *