Name *

First Name

Last Name

Phone *

Best phone number to reach you.

(###)

###

####

Date of Birth *

MM

DD

YYYY

Are you a current patient of Arbor Family Health? *

YES

NO

Do you have a mother, father, brother, or sister with diabetes? (A family history of diabetes could contribute to your risk of developing diabetes.) *

YES

NO

How old are you? (You are at higher risk for diabetes as you get older.) *

Under 40

40 - 49

50 - 59

60+

What race or ethnicity best describes you? (People of certain racial and ethnic groups are more likely to develop Type-2 Diabetes.) *

African American

American Indian or Alaskan Native

Asian American

Caucasian

Hispanic or Latino

Native Hawaiian or other Pacific Islander

Other

Have you ever been diagnosed with high blood pressure or hypertension? (Having high blood pressure or hypertension contributes to your overall risk for developing Type-2 diabetes.) *

YES

NO

Are you physically active? (Being inactive can increase your risk for Type-2 Diabetes.) *

YES

NO

Are you a man or woman? *

MAN

WOMAN

OTHER

If you are a woman, have you ever been diagnosed with gestational diabetes? (Gestational diabetes is a type of diabetes that develops during pregnancy. It goes away after pregnancy, but women who have gestational diabetes have an increased risk of developing Type-2 diabetes.) *

YES

NO

I am a man