Risk Assessment & Registration | St. Christopher Truckers Fund

This program is for professional truck drivers. I am a Class A, OTR truck driver.

1. How old are you? (copy) *

2. Are you a man or woman? *

3. If you are a woman, have you ever been diagnosed with gestational diabetes? *

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

5. Have you ever been diagnosed with high blood pressure? *

6. Are you physically active? *

7. What is your point value (Using chart below) *

Total Score: *

0.00

Driven to be Healty - Video Based Health Program

For scores 4 or below

Let's Get Started. Join Our Driving Down Diabetes Program Today!

Which of the following choices best fits your job description? *

Name *

First

Last

Birthdate *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please Upload Copy of CDL

Click or drag files to this area to upload. You can upload up to 2 files.

How did you learn about this program? *

Health Care Professional
Blood test results
Prediabetes risk test (short survey)
Someone at a community-based organization (church, community center, fitness center)
Family or friends
Current or past participant in the National DPP LCP
Employer or employer’s wellness plan
Health insurance plan
Media advertisements (social media, flyer, brochure, radio ad, billboard, etc.)

What is your level of education? *

What is your ethnicity? *

Is your BMI greater or equal to 25, or 23 if Asian American? (Use BMI Calculator below) *

Enter Your BMI below: *

Enter Your Weight below: *

Enter Your Height below: *

Have you ever been diagnosed with Type 1 or Type 2 diabetes before?

In the past year, have you had a fasting glucose or A1c test? *

What was the result? *

Do you NEED the following items? *