Diabetes Survey

Are you a resident of Mississippi?

You must be a resident of the state of Mississippi to participate.*

Yes No

Are you at least 65 years of age or older?

You must be at least 65 years old to take part in this program.*

Yes No

Are you a man or a woman?

*

What is your height and weight?

Feet*

Inches*

Pounds*

Please tell us your ethnicity/race.

*

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other/Prefer not to say

Choose all that apply.

Are you covered by Medicare?

Medicare*

Yes No

Select which Medicare you are covered under.

Medicare Type*

Medicare Original Medicare Advantage

Do you have diabetes (either Type 1 or Type 2)?

Diabetes*

Yes No

Do you have End Stage Renal Disease?

(ESRD) Kidney failure requiring regular dialysis.*

Yes No

Do you have a father, mother, brother or sister with diabetes?

A family history of diabetes could contribute to your risk for Type 2 diabetes.*

Yes No

Are you active for 2-3 hours or more each week?

Ways to be active include walking, dancing, yard work, or biking.*

You have a disqualifying factor.

We're sorry! Our programs are for people who are at least 60 year of age, are covered under Medicare, and do not have diabetes or End-Stage Renal Disease. Since you told us you are either under 60, NOT coveredy by Medicare or already have diabetes or End-Stage Renal Disase, you don't qualify to take part in a program. Please contact your health plan for help to manage your diabetes.

In the past year, has a doctor or other health care professional told you that you're at risk for diabetes, after giving you a blood test?

With prediabetes, a blood test shows that a person's blood sugar level is higher than normal, but not as high as in diabetes.*

Yes No

Has a doctor or other healthcare professional told you that you have high blood pressure?

High blood pressure can change your chance of getting Type 2 diabetes.*

Yes No

Congratulations!

You qualify for our program.