Prevent T2 Lifestyle Change Program - Orleans Community Health
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Do you have pre-diabetes?
Height & Weight Chart (for question #7)
Prediabetes Risk Test
1. How old are you?
*
Less than 40 years (0 points)
40-50 years (1 point)
50-59 years (2 points)
60 years or older (3 points)
2. Are you a man or a woman?
*
Man (1 point)
Woman (0 points)
3. If you are a woman, have you ever been diagnosed with gestational diabetes?
*
Yes (1 point)
No (0 points)
4. Do you have a mother, father, sister or brother with diabetes?
*
Yes (1 point)
No (0 points)
5. Have you ever been diagnosed with high blood pressure?
*
Yes (1 point)
No (0 points)
6. Are you physically active?
*
Yes (0 points)
No (1 point)
7. What is your weight status?
*
0 Point
1 Point
2 Points
3 Points
**Please reference the Weight Chart to determine status.
8. What is your score?
0-4 Points
5+ Points
If you scored 5 or higher you are likely to have prediabetes and are at risk for type 2 diabetes. However, only your doctor can tell for sure if you have type 2 diabetes or prediabetes. Talk to your doctor to see if additional testing is needed.
I'd like to register for the next Prevent T2 Diabetes Program.
*
Yes
No
I'd like more information on the Prevent T2 Diabetes Program.
*
Yes
No
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