Patient Information Form

PRE-DIABETES AND DIABETES RISK ASSESSMENT
Did you know that:
- Diabetes causes destruction of your eyesight, kidneys, nerves and heart
- Diabetes increases your risk for gum disease which leads to tooth loss
- Diabetes slows your ability to heal from injury and infection which can result in amputation
- 115 million adults in the US have either diabetes or pre-diabetes and 1/3 don't know it
Do you have Diabetes? Yes=1 points, No=0 points
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
1. Are you more than 10% above ideal body weight OR is your waist about 35" for women or 40" for men?
2. Do you have any biologic family member with a history of diabetes?
3. Are you of African American, Alaskan Native, American Indian, Hispanic, or Arabic descent?
4. Do you have a history of, or take medication for high blood pressure?
5.Do you have or take medication for high cholesterol or abnormal good/bad cholesterol ratio?
6.Do you experience tingling, pain or numbness in your hands or feet?
7. Do you experience unexplainable hunger, thirst or frequent urination?
8. Have you experienced blurred vision, cataracts or glaucoma?
9. Do your gums bleed when you brush or floss?
10. Are you over 35?
11. If you are over 35, are you also over 65?
Score total points:

0-2 Low risk for Pre-Diabetes and Diabetes

3+ Moderate to high risk: recommend further diagnostic testing or Pre-Diabetes and Diabetes
Should be Empty:

PRE-DIABETES AND DIABETES RISK ASSESSMENT