March Diabetes Alert Month Question Title * 1. How old are you? Younger than 40 (0 points) 40-49 years (1 point) 50-59 (2 points) 60 years or older (3 points) Question Title * 2. Are you a man or a woman? Man (1 point) Woman (0 points) Question Title * 3. If you are a woman, have you ever been diagnosed with gestational diabetes? Yes (1 point) No (0 points) None of the above Question Title * 4. Do you have a mother, father, sister, or brother with diabetes? Yes (1 point) No (0 points) Question Title * 5. Have you ever been diagnosed with high blood pressure? Yes (1 point) No (0 points) Question Title * 6. Are you physically active? Yes (0 points) No (1 point) Question Title * 7. What is your weight category? (see chart below) 0 points (my weight is not on scale for my height) 1 point (my weight for height is in 1st column) 2 points (my weight for height is in 2nd column) 3 points (my weight for height is in 3rd column) DID YOU KNOW THERE IS A SCREENING FOR TYPE 1 DIABETES?Type 1 Diabetes is an autoimmune disease where the pancreas stops producing insulin, a hormone that regulates blood sugar. Undiagnosed or untreated type 1 diabetes can lead to a dangerous condition called diabetic ketoacidosis (DKA). Many people don't know they have type 1 diabetes until DKA happens. Early screening in high risk individuals decreases the risk of DKA and gives time for people to consult with their healthcare provider. If any of the following risk factors apply to you, talk to your healthcare provider or contact a type 1 screening resource below. Risk factors include: 1. Have a family member with type 1 diabetes. Immediate family have 15 % greater risk.2. People with personal or family history of certain autoimmune diseases: Hashimoto's disease, Graves' disease, Celiac Disease. asktheexperts.org trialnet.org askhealth.org screenfortype1.com Question Title * 8. Do you have a family member with type 1 diabetes? Yes No Question Title * 9. Do you or someone in your family have Hashimoto's disease, Graves' disease or Celiac disease? Yes No If you answered yes to any of the above questions, talk with your healthcare provider about auto-antibody screening. To learn more about local resources and information on type 1 and type 2 diabetes, visit our website Purchase District Health Department-Diabetes Question Title * 10. What is your first name? Question Title * 11. What is your last name? Question Title * 12. Phone number or email address (best way to reach you) Thank you for taking the Prediabetes Risk Test! Please visit purchasehealth.org for more services and resources that can support your health! If you are one of the first 50 to take the test, you can get a free t-shirt. Please visit this link to provide your information. https://www.surveymonkey.com/r/risk26tee Done
