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Diabetes Risk Assessment
Please complete this brief assessment.
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Your name
Your answer
Today's Date
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MM
/
DD
/
YYYY
Your Date of Birth
MM
/
DD
/
YYYY
Your email address
*
Your answer
Your phone number
*
Your answer
What is the best way to contact you?
*
Email
Phone
How old are you?
*
Less than 40 years
40-49 years
50-59 years
60 years or older
What is your gender
*
Female
Male
Other/Prefer not to answer
For Females, Have you ever been diagnosed with gestational diabetes?
Yes
No
Clear selection
Have you ever been diagnosed with diabetes?
*
Yes
No
I'm not sure
Do you have a mother, father, sister, or brother with diabetes?
*
Yes
No
Have you ever been diagnosed with high blood pressure?
*
Yes
No
Are you physically active?
*
Yes
No
What race or ethnicity best describes you?
*
White
Asian
Hispanic and/or Latino
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Prefer not to say
Other:
Tell us more about yourself: Height in feet & inches
*
Your answer
Tell us more about yourself: Weight in pounds
*
Your answer
What would you be interested in learning about?
Blood sugar management
Weight Loss
Healthy Eating
Other:
Clear selection
If you selected "other" above, please describe what you are looking for assistance with:
Your answer
To obtain additional information, call 248-844-4530
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