Please only complete this form if someone from the team as asked you to do so.

Please also only complete this form if you do not have a diagnosis of Pre-Diabetes, Type 2 Diabetes or any other type of Diabetes.

Your Name:

Date of Birth:

Email:

Each answer has a number next to it. Add up the number next to each of your answers to get your total score.

1. How old are you?
49 or younger (0)50 – 59 (5)60 – 69 (9)70 or over (13)

2. Are you female or male?
Female (0)Male (1)

3. What is your ethnic background?
White British, European (0)Other Ethnic group (6)

4. Do you have a parent, sibling or child who has Type 1 or Type 2 Diabetes?
Yes (5)No (0)

5. What is your waist size?
Less than 90 cm (35.3 in) (0)90-99.9 cm (35.3-39.3 in) (4)100-109.9 cm (39.4-42.9 in) (6)110 cm (43 in) or above (9)

6. What is your Body Mass Index (BMI)? Use the NHS BMI calculator if you do not know.
Less than 25 (0)25-29.9 (3)30-34.9 (5)35 or above (8)

7. Has your doctor given you medicine for or told you that you have high blood pressure?
Yes (5)No (0)

Total score:

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