• Interest Form

  • Date of Birth*
     - -
  • Gender*
  •  -
  • Country of Birth*
  • Do you have Diabetes?*
  • Do you have a history of heart disease?*
  • Have you had diabetes whilst pregnant?*
  • Do you have polycystic ovarian syndrome?*
  • Do you have a chronic kidney disease?*

  •  

    By signing below, I confirm my wish to enrol in the Life! program and I consent to the following:

    a) Providing my personal information to Diabetes Victoria for the purposes of registration, administration and monitoring of my participation in the Life! program;

    b) For Equip4Life to release my health information to Diabetes Victoria to complete my referral into the program

    Please note you may receive a call from our team to clarify your interest.

  • Date*
     - -

  • THE AUSTRALIAN TYPE 2 DIABETES RISK ASSESSMENT TOOL (AUSDRISK)

  • 1. Your age group:*
  • 2. Your Gender*

  • 3. Your ethnicity/country of birth:

  • a. Are you of Aboriginal, Torres Strait Islander, Pacific Islander or Maori descent?*
  • b. Where were you born?*
  • 4. Have either of your parents, or any of your brothers or sisters been diagnosed with diabetes (type 1 or type 2)?*
  • 5. Have you ever been found to have high blood glucose (sugar) for example, in a health examination, during an illness, during pregnancy?*
  • 6. Are you currently taking medication for high blood pressure?*
  • 7. Do you currently smoke cigarettes or any other tobacco products on a daily basis?*
  • 8. How often do you eat vegetables or fruit?*
  • 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)?*

  • Complete either the 1 or 2 below, as appropriate:

  • 1.M.For those of Asian or Aboriginal or Torres Strait Islander descent:
  • 1.F.For those of Asian or Aboriginal or Torres Strait Islander descent:
  • 2.M.For all others:
  • 2.F.For all others:
  • Should be Empty: