Risk Assessment & Registration | St. Christopher Truckers Fund

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

Yes
No

1. How old are you? *

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

If your score is 4 or below, the CDC states that you are at a low risk for developing diabetes; however, you are still welcome to participate in our Diabetes Prevention Program or register for Healthy Habits for the Long Haul program.

Healthy Habits for the Long Haul

If you scored 5 or higher, you are at increased risk for having prediabetes. If you are a CLASS A OTR driver we encourage you to register for the Diabetes Prevention Program. To register, fill out the information below.

REGISTRATION FORM

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

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Birthdate *

How are you affiliated with the trucking industry? *

Truck Driver
Spouse
Other

Are you an OTR driver, away from home 4+ nights/week? *

Yes
No

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? *

Employer (employer will NOT be notified of participation)

What is your current weight? *

What is your BMI? *

Have you been diagnosed with any of the following?

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

What was the result? *

On a scale of 1 to 5, how would you rank your overall health when it comes to energy level?

Selected Value: 1

1 - very low energy, 5 - very high energy level

On a scale of 1 to 5, how would you rank your overall health when it comes to movement/activity?

Selected Value: 1

1 - completely sedentary, 3 - activity a few times each week, 5 - active for an hour each day

On a scale of 1 to 5, how would you rank your overall health when it comes to sleep?

Selected Value: 1

1 - consistently poor sleep, 5 - sleep is consistently great

On a scale of 1 to 5, how would you rank your overall health when it comes to emotional health?

Selected Value: 1

1 - very poor, 5 - great

How many bottles of water (16.9 oz) do you currently drink on a daily basis?

Selected Value: 1

1 - one bottle of water, 5 - five or more bottles of water

How many servings of fruit and vegetables do you eat on a daily basis?

Selected Value: 1

What are your biggest healthy living challenges while out on the road? *

What are your current health goals? *

What are you hoping to learn or gain from the Diabetes Prevention Program? *

Which of the following devices do you currently have? *

St. Christopher Fund is the creator and facilitator of the Healthy Habits and Diabetes Prevention courses. SCF employees are not doctors, do not diagnose or treat medical conditions, and will not provide information outside of their scope of practice. *

By checking this box, you agree that you understand this information.