QUESTIONNAIRE

People who pay careful attention to their health Smoking

What is your smoking status?
22 can protect themselves against diabetes and its
I never smoked 0 points
consequences. Why not test your risk! I used to smoke on average
fewer than 20 cigarettes a day 0 points
I used to smoke on average
ARE YOU AT
RISK?
more than 20 cigarettes a day 3 points
I smoke on average fewer than
20 cigarettes a day 0 points
I smoke on average more than
20 cigarettes a day 6 points

Alcohol consumption
How many glasses of alcoholic beverages
Age do you drink a day?
How old are you? I drink no or only occasionally
<35 0 points 50-54 7 points alcoholic beverages 2 points
35-39 1 point 55-59 9 points 1-4 0 points
40-44 3 points 60-64 11 points >4 2 points
45-49 5 points 65-70 13 points
Height
Physical activity How tall are you in centimetres?
Are you physically active at least five hours per week? <152 11 points 176-183 3 points
No 1 point Yes 0 points 152-159 9 points 184-191 1 point
160-167 7 points ≥ 192 0 points
High blood pressure 168-175 5 points
Have you ever been diagnosed with high blood pressure?
No 0 points Yes 5 points Waist circumference
What is your waist circumference in centimetres?
High-fibre diet <75 0 points 100-104 24 points
What is your high-fibre cereal product 75-79 4 points 105-109 28 points
intake per day? 80-84 6 points 110-114 32 points
0g 5 points 150 g 2 points 85-89 12 points 115-119 36 points
50 g 4 points 200 g 1 point 90-94 16 points ≥120 40 points
100 g 3 points >200 g 0 points 95-99 20 points

Consumption of meat
How often do you eat red meat such as lamb or beef?
Never or very seldom 0 point Now add up your points! Total: ___ points
1-2 times a week 1 point
Evaluation
3-4 times a week 2 points
0-29 points 50-59 points
5-6 times a week 4 points
Your risk of having diabetes Your risk of developing
daily 5 points
is low. diabetes is high.
several times a day 8 points
30-39 points More than 59 points
Your risk of having diabetes Your risk of developing dia-
Coffee
is still low. betes is very high. Please
How many cups of coffee do you drink a day?
40-49 points consult your physician.
0-1 2 points
Your risk of having diabetes You may already have
2-5 1 point
is increased. diabetes.
>5 0 points

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6057237Fragebogen_eng.indd 2 13.01.2009 12:31:00 Uhr