Name *

First Name

Last Name

Date *

MM

DD

YYYY

1. Your age group *

Under 35 years [0 points]

35-44 years [2 points]

45 - 54 years [4 points]

55-64 years [6 points]

65 years or over [8 points]

2. Your gender *

Female [0 points]

Male [3 points]

3. Your ethnicity/country of birth *

3a. Are you of Aboriginal, Torres Strait Islander, Pacific Islander or Maori descent?

No [0 points]

Yes [2 points]

3b. Where were you born?

Australia [0 points]

Asia (including the Indian sub-continent), Middle East, North Africa, Southern Europe [2 points]

Other [0 points]

4. Have either of your parents, or any of your brothers or sisters been diagnosed with diabetes (type 1 or type 2)? *

No [0 points]

Yes [3 points]

5. Have you ever been found to have high blood glucose (sugar) (for example, in a health examination, during an illness, during pregnancy)? *

No [0 points]

Yes [6 points]

6. Are you currently taking medication for high blood pressure? *

No [0 points]

Yes [2 points]

7. Do you currently smoke cigarettes or any other tobacco products on a daily basis? *

No [0 points]

Yes [2 points]

8. How often do you eat vegetables or fruit? *

Every day [0 points]

Not every day [1 point]

9. On average, would you say you do at least 2.5 hours of physical activity per week (for example, 30 minutes a day on 5 or more days a week)? *

Yes [0 points]

No [2 points]

Men

Less than 90 cm [0 points]

90 – 100 cm [4 points]

More than 100 cm [7 points]

Women

Less than 80 cm [0 points]

80 – 90 cm [4 points]

More than 90 cm [7 points]

Men

Less than 102 cm [0 points]

102 – 110 cm [4 points]

More than 110 cm [7 points]

Women

Less than 88 cm [0 points]

88 – 100 cm [4 points]

More than 100 cm [7 points]