Diabetes Risk Assessment Form
1
of
5
Health Conditions
Do you have high blood pressure?
No
Yes
Do you have high cholesterol?
No
Yes
BMI Calculator
Metric (cm, kg)
Imperial (ft, in, lbs)
Height (cm)
Weight (kg)
Height (feet)
Height (inches)
Weight (lbs)
BMI will appear here
Have you had a stroke?
No
Yes
Have you had Coronary Heart Disease or Myocardial Infarction?
No
Yes
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Lifestyle Factors
Have you smoked at least 100 cigarettes in your life? (5 packs = 100 cigarettes)
No
Yes
Have you had any physical activity in the past 30 days outside of work?
No
Yes
Do you consume 1 or more fruits a day?
No
Yes
Are you a heavy drinker? (Adult men: more than 14 drinks/week, Adult women: more than 7 drinks/week)
No
Yes
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Healthcare Access
Was there a time in the past 12 months when you needed to see a doctor but couldn't due to the cost?
No
Yes
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Health Status
Would you say that in general your health is:
Select...
Excellent
Very Good
Good
Fair
Poor
Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
Do you have serious difficulty walking or climbing stairs?
No
Yes
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Demographics
Gender
Female
Male
Age Category
Select...
18-24 years
25-29 years
30-34 years
35-39 years
40-44 years
45-49 years
50-54 years
55-59 years
60-64 years
65-69 years
70-74 years
75-79 years
80-99 years
Annual Income in US$
Select...
Less than US$10,000
Less than US$15,000
Less than US$20,000
Less than US$25,000
Less than US$35,000
Less than US$50,000
Less than US$75,000
Less than US$100,000
Less than US$150,000
Less than US$200,000
US$200,000 or more
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