Diabetes Questionnaire

Your Name (required) :

Today's Date:

Address:

Your Email (required):

Telephone:

Date of Birth (required):

Sex (required): MaleFemale

Body Mass Index:
(see calculator in sidebar)

Waist circumference:
(measured below the ribs, usually at the level of the navel)

Do you usually have daily at least 30 minutes of physical activity at work and/or during leisure time (including normal daily activity)?
YesNo

How often do you eat vegetables, fruit or berries?
Every dayNot every day

Have you ever taken medication for high blood pressure on regular basis?
YesNo

Have you ever been found to have high blood glucose (eg in a health examination, during an illness, during pregnancy)?
YesNo

Have any of the members of your immediate family or other relatives been diagnosed with diabetes (type 1 or type 2)?
YesNo