Diabetes Assessment Form

Help clinical staff collect a patient's health and lifestyle information in one organized place to assess diabetes risk.

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Full name

First Name

Last Name

Email address

Phone number

Date of birth

Gender

Male Female Other

Height (in cm)

Weight (in kg)

Do you have a family history of diabetes?

Yes No

Have you been diagnosed with high blood pressure?

Yes No

Have you been diagnosed with high cholesterol?

Yes No

Do you exercise regularly?

Yes No

How often do you consume sugary drinks or foods?

Never Rarely Sometimes Often Daily

Do you smoke?

Yes No

Are you currently taking any medication?

Yes No

Is there anything else you'd like to share about your health or lifestyle?

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