Diabetes Risk Form

People who pay careful attention to their health can protect themselves against diabetes and its consequences. Why not test your risk!

Name: *

Email: *

Phone: *

Personal Information-1

Physical activity: *

	Yes	No
Are you physically active at least five hours per week?

High blood pressure: *

	Yes	No
Have you ever been diagnosed with high blood pressure (More than 120/80) ?

Personal Information-2

High-fibre diet: *

Consumption of meat: *

Coffee: *

	0-1	2-5	>5
How many cups of coffee do you drink a day?

Personal Information-3

Smoking: *

	I never smoked	I used to smoke on an average fewer than 20 cigarettes a day	I used to smoke on an average more than 20 cigarettes a day	I smoke on an average fewer than 20 cigarettes a day	I smoke on an average more than 20 cigarettes a day
What is your smoking status?

Alcohol consumption: *

	I drink no or only occasionally alcoholic beverages	1-4	>4
How many glasses of alcoholic beverages do you drink a day?