Quiz - 360Care | For Diabetes Lifestyle Management

Diabetes Risk Assessment

Are you male or female?

Male Female

Tell us more about yourself

why does this matter?

Height

Weight

Using a tape measure, place it around your waist at the level of your belly button.

Measure after breathing out (do not hold your breath) and write your results on the line below. Then check the box that contains your measurement. (Note: this is not the same as the “waist size” on your pants).

MEN – Waist circumference: _ _ _ inches OR _ _ _ cm

WOMEN – Waist circumference: _ _ _ inches OR _ _ _ cm

Do you usually do some physical activity such as brisk walking for at least 30 minutes each day?

Yes No

How often do you eat vegetables or fruits?

Every day Not every day

Have you ever been told by a doctor or nurse that you have high blood pressure OR have you ever taken high blood pressure pills?

Yes No or don't know

Have you ever been found to have a high blood sugar either from a blood test, during an illness,or during pregnancy?

Yes No or don't know

Have you ever given birth to a large baby weighing 9 pounds (4.1 kg) or more?

Yes No, don't know, or not applicable

What is the highest level of education that you have completed?

Some high school or less High school diploma Some college or university University or college degree

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Diabetes Risk Assessment

Select your age group:

Are you male or female?

Tell us more about yourself

why does this matter?

Using a tape measure, place it around your waist at the level of your belly button.

MEN – Waist circumference: _ _ _ inches OR _ _ _ cm

WOMEN – Waist circumference: _ _ _ inches OR _ _ _ cm

Do you usually do some physical activity such as brisk walking for at least 30 minutes each day?

How often do you eat vegetables or fruits?

Have you ever been told by a doctor or nurse that you have high blood pressure OR have you ever taken high blood pressure pills?

Have you ever been found to have a high blood sugar either from a blood test, during an illness,or during pregnancy?

Have you ever given birth to a large baby weighing 9 pounds (4.1 kg) or more?

Have any of your blood relatives ever been diagnosed with diabetes?

Please check off which of the following ethnic groups your biological (blood) parents belong to:

What is the highest level of education that you have completed?

Send my test results and tips for preventing diabetes

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