Life! 
Taking action on diabetes
Template produced by North East Valley DGP. Version: 11/8/2010	The AustralianType2
DIABETES RISK TEST
for: <<Patient Demographics:Full Name>>	

1. Your Age	Score		6.  Are you taking medications for high blood pressure?	Score	
= <<Your age?>>			= <<Taking medications for high blood pressure?>>		
					
2. Your gender			7. Do you currently smoke cigarettes or any other tobacco products on a daily basis?		
= <<Gender>>			= <<Smoke cigarettes or other tobacco products? >>		
					
3. Your ethnicity/country of birth:			8. How often do you eat fruit / vegies? 		
3a. Are you of ATSI, Pacific Islander or Maori descent? = <<Are you of ATSI, Pacific Islander or Maori descent?>> 	
		= <<How often do you eat fruit/vegies?>>		
3b. Where were you born? = <<Where were you born?>> 					
					
4. Have any of your immediate family (mother, father, sibling)  been diagnosed with Type I or Type II diabetes?			9. On average. would you say you do at least 2.5 hours physical activity per week (e.g. 30 minutes a day on 5 or more days a week? 		
= <<Family relatives ever diagnosed with diabetes?>>  			= <<2.5 hrs/week of physical activity?>>		
					
5. Have you ever found to have high blood glucose (e.g. in a health examination, illness or pregnancy?)			10. Your waist measurement		
= <<Ever found to have high blood glucose>>			= <<Waist measurement?>>		
Subtotal			Subtotal		
			Total Risk Score	 	

Your risk of developing Type II diabetes within 5 years is:		
5 or less: low risk	Approximately 1 person in every 100 will develop diabetes.	
		
6-11: intermediate risk	For scores of 6-8 approximately 1 person in every 50 will develop diabetes and for scores of 9-11 approximately 1 person in every 30 will develop diabetes.	
		
12 or more: high risk	For scores of 12-15 approximately 1 person in every 14 will develop diabetes. For scores of 16-19, approximately one person in every 7 will develop diabetes.For scores of 20 and above approximately 1 person in every 3 will develop diabetes.	

If you scored 12 or more points, make an appointment to see your doctor

Test completed by:	<<Doctor:Name>> on <<Miscellaneous:Date>> at <<Practice:Name>>.