How old are you?

Less than 40 years(0 points)

40--49 years(1 point)

50---59 years(2 points)

60 years or older(3 points)

1.

Are you a man or a woman?

Man(1 Point) Woman(0)

2.

If you are a woman, have you ever been diagnosed with gestation diabetes

Yes(1 point) No(0 points)

3.

Do you have a mother, father, sister, or brother with diabetes?

Yes(1 point) No( 0 points)

4.

Have you ever been diagnosed with high blood pressure?

Yes(1 point) No(0 points)

5.

Are you physically active?

Are you physically active?

6.

What is your weight status?

(See chart at right)

7.