Blood Sugar Risk Assessment
Complete this assessment to help identify your risk for high blood sugar or diabetes.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Gender
*
Male
Female
Other / Prefer not to say
Height (in cm)
*
Weight (in kg)
*
Do you have a family history of diabetes? (parents, siblings)
*
Yes
No
Not sure
Have you ever been diagnosed with high blood sugar or diabetes by a healthcare professional?
*
Yes
No
Lifestyle Factors
*
Rows
Never
Sometimes
Often
Always
How often do you eat fruits and vegetables?
1
2
3
4
How often do you consume sugary drinks or snacks?
5
6
7
8
How often do you engage in physical activity (30 minutes or more)?
9
10
11
12
How often do you feel stressed?
13
14
15
16
Have you experienced any of the following symptoms recently? (Select all that apply)
*
Frequent urination
Increased thirst
Unexplained weight loss
Fatigue
Blurred vision
None of the above
If you have recently measured your blood sugar, please indicate your latest value (mg/dL)
Please provide any additional information or concerns you have regarding your blood sugar or health.
Submit Assessment
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