CANRISK - THE CANADIAN DIABETES RISK QUESTIONNAIRE

The following questions will help you to find out if you are at higher risk of having pre-diabetes or type 2 diabetes. Pre-diabetes is a condition where a person’s blood sugar levels are higher than normal, but not high enough to be diagnosed as diabetes. You can have pre-diabetes or undiagnosed type 2 diabetes without having any obvious warning signs or symptoms.

Knowing your risk can help you make healthy choices now that will reduce your risk or even prevent you from developing diabetes.

Please answer the questions as honestly and completely as you can. If you wish, a friend or family member can help you to complete this form. The answers to these questions are completely confidential. Answer all questions. Enter your scores for each question in the box on the right-hand side and then add them up to calculate your total risk score.

This questionnaire is intended for adults aged 40 to 74 years.

~ AS YOU GET OLDER, YOUR RISK OF DEVELOPING DIABETES GOES UP.

1. Select your age group:

o 40-44 years 0 points

o 45-54 years 7 points

o 55-64 years 13 points

o 65-74 years 15 points

2. Are you male or female?

o Male 6 points

o Female 0 points

~ BODY SHAPE AND SIZE CAN AFFECT YOUR RISK OF DIABETES.

3. How tall are you and how much do you weigh?

On the left~hand side of the 8MI chart beiow, circle your height, then on the bottom of the chart circle your weight. Find the square on the chart where your height crosses with your weight, and note which shaded area you fall into. For example, if you were 5 feet 2 Inches (or 157.5cm) and 163 pounds (or 74kg) you would fall in the LIGHT GREY area.

Select your BMI group from the following choices:

o White (BMlless than 25) 0 points

o Light grey (BMI 25 to 29) 4 points

o Dark grey (BMI 30 to 34) 9 points

o Black (BMI 35 and over) 14 points

4. Using a tape measure, place it around your waist at the level of your belly button.

Measure after breathing out (do not hold your breath) and write your results on the line below. Then check the box that contains your measurement. (Note: this is not the same as the “waist size” on your pants).

MEN - Waist circumference:

o Less than 94 cm or 37 inches 0 points

o Between 94-102 cm or 37-40 inches 4 points

o Over 102 em or 40 inches 6 points

WOMEN - Waist circumference:

o Less than 80 em or 31.5 inches 0 points

o Between 80-88 cm or 31.5-35 inches 4 points

o Over 88 em or 35 inches 6 points

~ YOUR LEVEL OF PHYSICAL ACTIVITY AND WHAT YOU EAT CAN AFFECT YOUR RISK OF DEVELOPING DIABETES.

5. Do you usually do some physical activity such as brisk walking for at least 30 minutes each day? This activity can be done while at work or at home.

o Yes 0 points

o No 1point

6. How often do you eat vegetables or fruits?

o Every day 0 points

o Not every day 2 points

~ HIGH BLOOD PRESSURE, HIGH BLOOD SUGAR, AND PREGNANCY-RELATED FACTORS ARE ASSOCIATED WITH DIABETES.

7. Have you ever been told by a doctor or nurse that you have high blood pressure OR have you ever taken high blood pressure pills?

o Yes 4 points

o No or don’t know 0 points

8. Have you ever been found to have a high blood sugar either from a blood test, during an illness, or during pregnancy?

o Yes 14 points

o No or don’t know 0 points

9. Have you ever given birth to a large baby weighing 9 pounds (4.1 kg) or more?

o Yes 1 point

o No, don’t know, or not applicable 0 points

~ SOME TYPES OF DIABETES RUN IN FAMILIES.

10. Have any of your blood relatives ever been diagnosed with diabetes?

Check ALL that apply.

o Mother 2 points

o Father 2 points

o Brothers/Sisters 2 points

o Children 2 points

o Other 0 points

o No/don’t know 0 points

Add your score.

Your combined score cannot be more than 8 points (2 points for each category, do not count multiple children or siblings twice)

11. Please check off which of the following ethnic groups your biological (blood) parents belong to:

MOTHER FATHER

o o White (Caucasian) o points

o o Aboriginal 3 points

o o Black (Afro-Caribbean) 5 points

o o East Asian (Chinese, Vietnamese, Filipino, Korean, etc.) 10 points

o o South Asian (East Indian, Pakistani, Sri Lankan, etc.) 11 points

o o Other non-white (Latin American, Arab, West Asian) 3 points

Choose only one score, the highest.

Do not add mother plus father scores together. (Your score cannot be more than 11 points for this section)

~ OTHER FACTORS ARE ALSO RELATED TO DEVELOPING DIABETES.

12. What is the highest level of education that you have completed?

o Some high school or less - 5 points

o High school diploma - 1 point

o Some college or university - 0 points

o University or college degree - 0 points

Add up your points from questions

1 to 12

Total Score:

These risk scores are in no way a substitute for actual clinical diagnosis.

If you have any concerns, please consider discussing your results with a health care practitioner (eg. family doctor, nurse practitioner, pharmacist).

Lower than 21 - low risk

Your risk of haVing pre-diabetes or type 2 diabetes is fairly low, though It aiways pays to maintain a healthy !ifestyle

21 - 32 - moderate risk

Based on your identified risk factors, your risk of having pre-diabetes or type 2 diabetes is moderate. You may wish to consult with a health care practitioner about your risk of developing diabetes.

33 and over - high risk

Based on your identified fisk factors, your fiSk of haVing pre-diabetes or type 2 diabetes is high. You may wish to consult with a health care practitioner to discuss getting your blood sugar tested.

Diabetes is a serious chronic disease and uncontrolled diabetes can lead to heart disease, kidney disease and other conditions.

While you can’t change some factors such as, age, gender, family history, and ethno-cultural background, other risk factors for diabetes may respond to lifestyle changes. These include weight, physical activity, diet, and smoking.

If your BMI is 25 or higher, lowering your weight may help you reduce your risk of developing type 2 diabetes. Even a small change in body weight or physical activity can reduce your risk. Embrace a healthy balanced diet which emphasizes vegetables, fruit, and whole grains. Consult Canada’s Food Guide for helpful suggestions. If you are not active, begin slowly and increase your activity gradually. Check with your doctor before beginning any exercise program.

If you smoke, it’s never too late to quit. Every step you take to improve your health counts!

Thank you for completing the Canadian Diabetes Risk Questionnaire.

Public Health Agency of Canada. 2011