The Australian Type 2 Diabetes Risk Assessment (AUSDRISK)

Participation consent form 
(only for Prevent Diabetes Live Life Well participants)	
•	I have read and understood the Participant Information Sheet.
•	I freely choose to fill in the Australian Type 2 Diabetes Risk Assessment tool and, if appropriate undergo a blood test.
•	I understand that I can withdraw from the program at any time.
•	I understand that the program is strictly confidential.
•	I agree to participate in this program.	
I, 		
of 		
My GP is: 		
	
Signature:	
	Date Completed: 	

1. Your Age Group?		8. How often do you eat vegetables or fruit?	
Under 35 years	0 points	Everyday 	0 points	
35-44 years	2 points	Not everyday	1 point	
45-54 years	4 points			
65 years and over	8 points	9. On average, would you say you do at least 2.5 hrs of physical activity p/week (eg 30 min/day on 5 or more days a week)?	
2. Your Gender?		Yes	0 points	
Female	0 points	No	2 points	
Male	3 points			
		10. Your waist measurement taken below the ribs (usually at the level of navel)?	
3. Ethnicity/Country of Birth		For those of Asian or Aboriginal/Torres Strait Islander descent:	
3a. Are you of Aboriginal, Torres Strait Islander or Maori descent?	Men                  Women		
No	0 points	< 90 cm            <80 cm	0 points	
Yes	3 points	90-100 cm        80-90 cm	4 points	
		>100 cm           > 90 cm	7 points	
3b. Where were you born?				
Asia (incl. the Indian sub-continent), Middle East, North Africa, Southern Europe	2 points	For all others		
Other	0 points	Men                  Women		
		< 102 cm            <88 cm	0 points	
4. Have either of your parents, or any of your brothers and sisters been diagnosed with diabetes (type 1 or type 2)?	102-110 cm        88-100 cm
> 110 cm            > 100 cm	4 points
7 points
	
No	0 points	ADD UP YOUR SCORE:		
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                                                                       	Your risk of developing type 2 diabetes within 5 years*:
Less than 5: Low Risk
Approx. 1 person in every 100 will develop diabetes
6-14: Intermediate Risk
Scores 6-8, approx. 1 person in  50 will develop diabetes
Scores 9-14, approx. 1 person in 20 will develop diabetes
15 or More: High Risk
Scores 15-19, approx. 1 person in 7 will develop diabetes
Scores above 20, approx. 1 person in 3 will develop diabetes	
6. Are you currently talking medication for high blood pressure? 		
No	0 points	If you scored 15 or more points, it is important that you discuss the score with your doctor.	
Yes	2 points		
			
7. Do you currently smoke cigarettes or any other tobacco products on a daily basis?	* The overall risk score may overestimate the risk of diabetes in those aged less than 25 years and underestimate the risk of diabetes in people of Aboriginal & Torres Strait Islander descent.	
No	0 points		
Yes	2 points			
		Capillary Blood Glucose Test result: