Prediabetes Risk Assessment

This assessment identifies factors that may increase your risk of developing prediabetes or type 2 diabetes. Results should be reviewed with your healthcare provider, who can recommend appropriate testing, lifestyle modifications, or follow-up care if needed. If you have any questions about your risk assessment or questions about the Diabetes Prevention Program (DPP) call (313) 876-8300 or email HFHSDPP@hfhs.org.

*Asterisk indicates required field. Please keep track of the points you assign for each question. You will be asked to provide your total score at the end of the form.

I have been diagnosed as having prediabetes: Yes No

I have been diagnosed as having Type 1 or Type 2 Diabetes Yes No

How old are you?

Are you a man or a woman? Man (1 point) Woman (0 points)

If you are a woman, have you ever been diagnosed with gestational diabetes? Yes (1 point) No (0 points)

Do you have a mother, father, sister or brother with diabetes? Yes (1 point) No (0 points)

Have you ever been diagnosed with high blood pressure? Yes (1 point) No () points)

Are you physically active? Yes (0 points) No (1 point)

What is your weight category? *REfer to the table at the bottom of the page and enter your points Enter Total Score – Add point totals together that are associated with your above responses

If your total score is 5 or higher, you are at increased risk for having prediabetes and are at high risk for type 2 diabetes. However, only your doctor can tell for sure if you have type 2 diabetes or prediabetes, a condition in which blood sugar levels are higher than normal, but not high enough yet to be diagnosed with type 2 diabetes. Talk to your doctor to see if additional testing is needed

First and Last Name: Phone Number: Email: Physician:

Height and Weight Point Assignment Table
Height	1 Point Weight Range (lbs.)	2 Point Weight Range (lbs.)	3 Point Weight Range (lbs.)
4'10"	119-142	143-190	191+
4'11"	124-147	148-197	198+
5'0"	128-152	153-203	204+
5'1"	132-157	158-210	211+
5'2"	136-163	164-217	218+
5'3"	141-168	169-224	225+
5'4"	145-173	174-231	232+
5'5"	150-179	180-239	240+
5'6"	155-185	186-246	247+
5'7"	159-190	191-254	255+
5'8"	164-196	197-261	262+
5'9"	169-202	203-269	270+
5'10"	174-208	209-277	278+
5'11"	179-214	215-285	286+
6'0"	184-220	221-293	294+
6'1"	189-226	227-301	302+
6'2"	194-232	233-310	311+
6'3"	200-239	240-318	319+
6'4"	205-245	246-327	328+

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