Prediabetes Risk Assessment

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First and Last Name *

Email Address *

Do you have a mother, father, brother, or sister with diabetes? (A family history of diabetes could contribute to your risk of developing diabetes.) *

Yes

How old are you? (You are at higher risk for diabetes as you get older.) *

Younger than 40 years

40-49 years

50-59 years

60+ years

What race or ethnicity best describes you? (People of certain racial and ethnic groups are more likely to develop Type-2 Diabetes.) *

African American

American Indian or Alaskan Native

Asian American

Caucasian

Hispanic or Latino

Native Hawaiian or other Pacific Islander

Other

Have you ever been diagnosed with high blood pressure or hypertension? (Having high blood pressure or hypertension contributes to your overall risk for developing Type-2 diabetes.) *

Yes

Are you physically active? (Being inactive can increase your risk for Type-2 Diabetes.) *

Yes

Are you a man or woman? *

Man

Woman

Other:

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.) *

Yes

I am a man.

Other:

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? *

Phone number (If you want to be contacted with information on The Woman's Foundation's Healthy Me Lifestyle Program and your Prediabetes Risk Assessment results.)

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