Interest Form

1. Your age group:*

2. Your Gender*

Female (0 points)Male (3 points)

3. Your ethnicity/country of birth:

a. Are you of Aboriginal, Torres Strait Islander, Paciﬁc Islander or Maori descent?*

No (0 points)Yes (2 points)

b. Where were you born?*

Australia (0 points)Asia, Middle East, North Africa, Southern Europe (2 points)Other (0 points)

4. Have either of your parents, or any of your brothers or sisters been diagnosed with diabetes (type 1 or type 2)?*

No (0 points)Yes (3 points)

5. Have you ever been found to have high blood glucose (sugar) for example, in a health examination, during an illness, during pregnancy?*

No (0 points)Yes (6 points)

6. Are you currently taking medication for high blood pressure?*

No (0 points)Yes (2 points)

7. Do you currently smoke cigarettes or any other tobacco products on a daily basis?*

No (0 points)Yes (2 points)

8. How often do you eat vegetables or fruit?*

Everyday (0 points)Not everyday (1 point)

9. On average, would you say you do at least 2.5 hours of physical activity per week (for example, 30 minutes a day on 5 or more days a week)?*

Yes (0 points)No (2 points)

10. Your waist measurement taken below the ribs (usually at the level of the navel, while standing):*

Waist measurement in cm

1.M.For those of Asian or Aboriginal or Torres Strait Islander descent:

Less than 90cm (0 points)90–100cm (4 points)More than 100cm (7 points)

1.F.For those of Asian or Aboriginal or Torres Strait Islander descent:

Less than 80cm ( 0 Points)80–90cm (4 points)More than 90cm (7 points)

2.M.For all others:

Less than 102cm ( 0 Points)102–110cm (4 points)More than 110cm (7 points)

2.F.For all others:

Less than 88cm ( 0 Points)88 - 100cm (4 points)More than 100cm (7 points)

AUSDRISK score - Do not fill - Read Only

Total Points

THE AUSTRALIAN TYPE 2 DIABETES RISK ASSESSMENT TOOL (AUSDRISK)