am i at risk of type 2 diabetes? add up your score ... · 9/21/2016 · for more information...
TRANSCRIPT
For more information please call 13 RISK (13 7475) or visit www.lifeprogram.org.au
206 Queensberry St, Carlton Vic 3053T: 03 8648 1880 F: 03 9667 1757E: [email protected]
AM I AT RISK OF TYPE 2 DIABETES?
PLEASE CALL TO DISCUSS MY RISK
ADD UP YOUR SCORE (AUSDRISK SCORE OVERLEAF)
Title Mr Mrs Ms Miss
Name
Dateofbirth
Address
Phone
Doyouhavediabetes? Yes No
Doyouhaveahistoryofheartdisease? Yes No
Haveyouhaddiabeteswhilstpregnant? Yes No
Height
Weight
BMI
Bysigningbelow,IconfirmmywishtoenrolintheLife!programandIconsenttothefollowing;
Providing personal information, registration, administration and monitoring of my participation in the Life! program;
For my health professional to release my health information to Diabetes Victoria to complete my referral into the program; and;
To be contacted by Diabetes Victoria regarding research and information.
PLEASESIGN&DATEHERE
/ /Signature Date
kg/m2
1. Howoldareyou?
18 – 35 years 0 points35–44 years 2 points45–54 years 4 points55–64 years 6 points65 years or over 8 points
2. Yourgender
Female 0 points Male 3 points
3. Yourethnicity/countryofbirth:
a. AreyouofAboriginal,TorresStraitIslander,PacificIslanderorMaoridescent?
No 0 pointsYes 2 points
b.Wherewereyouborn?
Australia 0 pointsAsia (the subcontinent), Middle East, North Africa, Southern Europe 2 pointsOther 0 points
4. Doyouhaveaparent,brotherorsisterwithdiabetes(type1ortype2)
No 0 pointsYes 3 points
5. Haveyoueverbeentoldyouhavehighbloodsugar(glucose)?(inahealthassessment,whenyou’vebeensick,orpregnant)
No 0 pointsYes 6 points
6. Doyoutakemedicineforhighbloodpressure?
No 0 pointsYes 2 points
7. Doyousmokeeveryday?
No 0 points Yes 2 points
8. Doyoueatvegetablesorfruiteveryday?
Yes 0 pointsNo 1 points
9. Doyouexercisefor30minutesonmostdays?
Yes 0 pointsNo 2 points
10.Whatisyoursize(ormeasurearoundyourbellybutton)
ForthoseofAsianorAboriginalorTorresStrait
Islanderdescent:
Men WomenLess than 90cm Less than 80cm 0 points90–100cm 80–90cm 4 pointsMore than 100cm More than 90cm 7 points
Forallothers:
Men Women
Less than 102 cm Less than 88 cm 0 points102–110cm 88–100cm 4 pointsMore than 110cm More than 100cm 7 points
Add up your points
ANSWER THESE QUESTIONS TO FIND OUT IF YOU COULD DEVELOP TYPE 2 DIABETES
What your score means Yourscoreshowshowlikelyyouaretodeveloptype2diabeteswithin5years.Ifyouscored12 or moreyouareathigh riskofdevelopingtype2diabetes.
6 – 11 —mediumrisk
5 or less—lowrisk
For more information please call 13 RISK (13 7475) or visit www.lifeprogram.org.au
206 Queensberry St, Carlton Vic 3053T: 03 8648 1880 F: 03 9667 1757E: [email protected]
This has been adapted from the Australian Type 2 Diabetes Risk Assessment Tool which was originally developed by the International Diabetes Institute on behalf of the
Australian, State and Territory Governments as part of the COAG Diabetes reducing the risk of type 2 diabetes initiative.