Prediabetes Risk Assessment
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Email *
First and Last Name *
How old are you?  (You are at a higher risk for type 2 diabetes the older you are.) *
Are you a man or woman?  Men are more likely than women to have undiagnosed diabetes; one reason may be that they are less likely to see their doctor regularly. *
If you are a woman, have you ever been diagnosed with gestational diabetes? (Gestational diabetes is a type of diabetes that develops during pregnancy. It goes away after pregnancy, but women who have gestational diabetes have an increased risk of developing type 2 diabetes.) *
Do you have a mother, father, sister, or brother with diabetes? (A family history of diabetes could contribute to your risk for type 2 diabetes.) *
Have you ever been diagnosed with high blood pressure? (Having high blood pressure contributes to your overall risk for type 2 diabetes.) *
Are you physically active? (Being inactive can increase your risk for type 2 diabetes.) *
How tall are you in inches? (The combination of your height and weight lets us know your Body Mass Index or BMI. People with higher BMIs are at a higher risk of developing Type-2 diabetes.) Example: 5'7" = 67 inches *
What is your current weight in pounds? *
What race or ethnicity best describes you? (People of certain racial and ethnic groups are more likely to develop type 2 diabetes than others.) *
Phone number (If you want to be contacted with information on HEAL-MIND BODY SOUL's Diabetes Prevention Program and your Prediabetes Risk Assessment results.) *
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