The Australian Type 2 Diabetes Risk Assessment (AUSDRISK)

Participation consent form 
(only for Prevent Diabetes Live Life Well participants)	

I, 	

of 	

My GP is: 	

•	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.	
	
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	

Yes	
2 points	

	If you scored 15 or more points, it is important that you discuss the score with your doctor.	
			
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: