Diabetes Prevention, Participant Inquiry

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email *

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

Yes

No

A family history of diabetes could contribute to your risk for type 2 diabetes.

Have you ever been diagnosed with high blood pressure?

Yes

No

Having high blood pressure contributes to your overall risk for type 2 diabetes.

How old are you?

You are at a higher risk for type 2 diabetes the older you are.

What Race or ethnicity best describes you?

People of certain racial and ethnic groups are more likely to develop type 2 diabetes than others.

Are you physically active?

Yes

No

Being inactive can increase your risk for type 2 diabetes.

Are you a man or a woman?

Man

Woman

Men are more likely than women to have undiagnosed diabetes; one reason may be that they are less likely to see their doctor regularly.

How tall are you?

The combination of your weight and height lets us know your Body Mass Index or BMI. People with higher BMIs are at a higher risk.

What is your weight?

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