Am I at risk for having prediabetes?

What is prediabetes?

Prediabetes occurs when blood glucose levels (sugar) are higher than normal, but not high enough for a diabetes diagnosis. If no lifestyle changes occur, prediabetes can eventually become a diagnosis of type 2 diabetes.

I consent to taking survey and providing my personal information below

Submission Date*

First name*

Last name*

Contact phone number*

(xxx) xxx-xxxx

Contact email address*

Your results from this survey will be sent to this email

Date of birth*

(MM/DD/YYYY) Month, Day, Year

How old are you?*

Younger than 40 years

40 to 49 years

50 to 59 years

Over 60 years

Do you have a mother, father, sister, or brother with diabetes?*

Yes

Have you ever been diagnosed with high blood pressure?*

Yes

Are you physically active?*

*30 minutes a day for at least 5 days a week or 150 minutes per week

Yes

Are you male or female?*

Male

Female

If you are female, have you ever been diagnosed with gestational diabetes?

Yes

Please tell us more about yourself: Please choose your height and weight from the drop-down list below.*

Example: for option 4'11 it means you are 4 feet and 11 inches tall. The second number is your weight

Select

This survey was adapted from: https://doihaveprediabetes.org/

Send results to Diabetes Prevention Program*

Yes, send my responses to the Diabetes Prevention Program

No, do not send my responses to the Diabetes Prevention Program

Please review that all questions have been answered before submitting this form

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