This document contains a 14 question self-assessment questionnaire to evaluate risk factors for diabetes mellitus. The questions cover genetic/ethnic factors, family history of diabetes, obesity, physical activity levels, stress levels, pregnancy, alcohol use, smoking, cholesterol levels, diet, hypertension, heart disease, and long term medication use. Scoring involves tallying the number of "yes" responses, with a higher total score indicating a higher risk of having diabetes.

1. ## Question Yes No
1 Genetic/Ethnic Factor: Are you an Asian Indian?
2 Family History: Is there a family history of diabetes?
3 Obesity/Body Mass Index (BMI): Is your BMI > 30?
4 Sedentary Lifestyle: Do you maintain a daily physical activity schedule?
5 Domestic Stress: Do you have mental stress at home?
6 Educational/ Occupational stress: Are you stressed at school/workplace?
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Self-Assessment Questionnaire
for Diabetes Mellitus
. . . Continued
Pregnancy (Gestational Diabetes): Are you pregnant?
Page 1 This question applies only to female respondents
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2. ## Question Yes No
8 Alcohol: Are you an Alcoholic?
9 Smoking: Are you a Smoker?
10 Cholesterol: Do you have high Cholesterol?
11 Diet: Are you on a diet schedule as advised by a Doctor/Dietician?
12 Hypertension: Are you Hypertensive?
13 Ischemic heart disease: Do you have heart disease?
14 Long term Medication: Are you on any long term medication?
Page 2
Self-Assessment Questionnaire
for Diabetes Mellitus
What is your score (add all the ticks in the blue circle)? Higher the score, higher your risk of Diabetes!
www.asian-indian-diabetes-foundation.org