Diabetes Risk Assessment

Please provide the following information for the health risk assessment:

Name:

Phone Number:

Healthcare provider's email:

Gender:

Date of Birth:

Please complete the form. Choose an option for each question*

Questions
How old are you?

0-25 26-40 41-60 60+

What is your BMI?

0-25 26-30 31-35 35+

Does anybody in your family have diabetes?

No. Grandparent Sibling Parent

How would you describe your diet?

Low-sugar Normal sugar Quite high sugar High sugar Extremely high sugar

Result:

Risk Level: