INTEGRIS Diabetes Center: Am I at Risk for Diabetes?

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Am I at Risk for Diabetes?

Risk Factors
1. Does anyone in your family have diabetes or high blood sugar?	£ YES £ NO
2. Are you African American?	£ YES £ NO
3. Are you Hispanic?	£ YES £ NO
4. Are you American Indian?	£ YES £ NO
5. Are you Asian American?	£ YES £ NO
6. Do you have high cholesterol/blood fats?	£ YES £ NO
7. Do you have high blood pressure?	£ YES £ NO
8. Have you given birth to a baby greater than 9 pounds at birth, or had gestational diabetes?	£ YES £ NO £ N/A
9. Do you have a history of heart disease?	£ YES £ NO
10. Are you over the age of 40?	£ YES £ NO
11. Are you overweight especially in the stomach area?	£ YES £ NO
12. Do you have a sedentary lifestyle? (ex. Sit at work, only household chores, no regular activity)	£ YES £ NO

Signs & Symptoms
1. Frequent urination	£ YES £ NO
2. Thirst, dry "cotton" mouth	£ YES £ NO
3. Blurry vision	£ YES £ NO
4. Recent weight loss	£ YES £ NO
5. Unusual hunger	£ YES £ NO
6. Burning or tingling in hands or feet	£ YES £ NO
7. Frequent infection	£ YES £ NO
8. Change in mod, trouble concentrating	£ YES £ NO

Diagnosis Protocol for Diabetes

Diabetes Detective: Examining the Evidence

Diabetes Detective: Uncovering the Complications

**Please print this page and take it to your doctor if you answered yes on two or more risk factors or have any of the signs and symptoms of diabetes.**

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INTEGRIS Diabetes Center
3300 N.W. Expressway
Oklahoma City, OK 73112

Patient Information
(405) 949-3011