CDC Screening

First Name: Last Name: Your Email: Your Phone (10 digits, no punctuation): How old are you?

Younger than 40 years (0 points)      40–49 years (1 point)      50–59 years (2 points)      60 years or older (3 points)

Are you a man or a woman?

Man(1 Point)     Woman(0 Points)

If you are a woman, have you ever been diagnosed with gestational diabetes?

Yes (1 point)      No (0 points)

Do you have a mother, father,sister, or brother with diabetes?

Yes (1 point)      No (0 points)

Have you ever been diagnosed with high blood pressure?

Yes (1 point)      No (0 points)

Are you physically active?

Yes (1 point)      No (0 points)

What is your weight category?

See the Chart below

Total Score