Prediabetes-ADA Risk Test:
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CALCULATED BMI:
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Do you have diabetes?
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Are you a female or male (by birth)?
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What year were you born?
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How much do you weigh (in pounds)?
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How tall are you?
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Do you have a parent, sister or brother with diabetes?
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Are you physically active?
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Have you ever been diagnosed with gestational diabetes?
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Have you ever been diagnosed with high blood pressure (hypertension)?
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The last question we have is to please indicate your ethnicity:
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Gestational Diabetes-NICHD Risk Screener
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CALCULATED BMI:
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How much do you weigh (in pounds)?
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Do you have a parent, sister or brother with diabetes?
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The last question we have is to please indicate your ethnicity:
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What year were you born?
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Have you ever been pregnant?
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In a previous pregnancy, did you have gestational diabetes?
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In a previous pregnancy, did you have a stillbirth or miscarriage?
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In a previous pregnancy, did you have a large baby (weighing larger than 9 pounds)?
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Do you have Polycystic Ovary Syndrome(PCOS) or another health condition linked to problems with insulin?
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Ever had problems with insulin or blood sugar, such as insulin resistance, glucose intolerance or "prediabetes":
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Do you have high blood pressure (hypertension)?
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Do you have high cholesterol?
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Do you have heart disease?
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PHQ-2 Depression
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During the past month, have you been bothered by feeling down, depressed, or hopeless?
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During the past month, have you often been bothered by very little interest or pleasure in doing things?
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PTSD - (PC-PTSD-5)
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Ever experienced any of the following: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, war, seeing someone killed or seriously injured, a loved one dying through homicide or suicide?
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Suicide - (PHQ-9 - Suicide Question)
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During the past month, Have you had thoughts that you would be better off dead or of harming yourself?
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Anxiety - GAD-2
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Over the last 2 weeks, have you been bothered by feeling nervous, anxious, or on edge?
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Over the last 2 weeks, have you been bothered by not being able to stop or control worrying?
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CAGE-AID
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Ever felt you ought to cut down on your drinking or drug use?
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Have people annoyed you by criticizing your drinking or drug use?
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Have you felt bad or guilty about your drinking or drug use?
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Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
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Incontinence (DAISy Research Group - Question 1)
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Are you 65 or older?
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During the past three months, have you leaked urine?
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Fall Risk
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Are you 65 or older?
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Have you had a fall or fall-related injury within the past year?
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Do you suffer from blacking out or loss of consciousness?
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Do you have a tendency to fall?
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A sensation of movement of yourself or the room: spinning or tilting?
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Lightheadedness or feeling that you are going to faint?
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Loss of balance?
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Disassociation or disorientation with the world?
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Dizziness or lightheaded when standing up or getting out of bed?
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Difficulty hearing?
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PCF Prostate Awareness Score:

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What year were you born?
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Do you have a family member who has had prostate, colon, pancreatic, ovarian or breast cancer?
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The last question we have is to please indicate your ethnicity:
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Medicare Annual Wellness Questions:
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Are you 65 or older?

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In general would you say your health is

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How often do you get the social and emotional support you need?

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Are you having trouble with your hearing?

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Are you having trouble with your vision?

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Do you or your family members report that you have difficulty remembering things?

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If you are able to ambulate, how many falls have you had in the past one year?

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If you had a fall, was there any injury with the fall?

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Are you afraid of falling?

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How many days per week do you usually exercise?

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On a typical day, how many servings of fruits and/or vegetables do you eat?

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On a typical day, how many servings of high fiber or whole grain foods do you eat?

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On a typical day, how many servings of milk products do you have?

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Do you have a tooth or dental problem that make it difficult to eat?

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Are you able to dress yourself?

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Are you able to bathe yourself?

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Are you able to manage stairs?

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Are you able to use the telephone?

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Are you able to do housework by yourself?

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Are you able to prepare meals by yourself?

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Are you able to do laundry?

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Are you able to manage medications?

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Are you able to handle money?

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Are you able to shop?

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Are you able to travel?

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Does your home have good lighting near doors, stairs and hallways?

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Does your home have clutter free floors and stairs?

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Does your home have sturdy handrails on all stairs?

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Does your home have grab bars present in bath areas?

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Does your home have non-slip mats?

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Does your home have non-slip carpets and throw rugs?

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Does your home have working smoke detectors?

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Does our home have working carbon monoxide detectors?

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Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things?

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Over the past 2 weeks, how often have you been bothered by feeling down, depressed or hopeless?

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Do you have a Living Will, Power of Attorney for Health Care(POA), or POLST(Physician's Orders for Life Sustaining Treatment) Form?

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