The Diabetes Report Card tool was designed using peer-reviewed medical literature and guidelines of national medical organizations.

Please fill out the following questions and then click the "next step" button.

What is your gender? What is your date of birth? Male Female [Month] Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec [Day] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 [Year] 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Enter your height: Enter your weight: What is your waist size? feet   inches lbs. inches

Enter your most recent Hemoglobin A1c result: % I don't know

What is your average blood pressure? (if you do not know, select an appropriate answer) /   I know that my blood pressure is too high I think my blood pressure is a little high I think my blood pressure is OK I have no idea what my blood pressure is

What is your total cholesterol level? What is your 'bad' (LDL) cholesterol level? What is your 'good' (HDL) cholesterol level? mg/dl I don't know mg/dl I don't know mg/dl I don't know

If you answered 'I don't know' to the previous 3 questions, please select an appropriate answer below: I take medication for my cholesterol, but it is still too high I have been told that my cholesterol is high, but I'm not taking medications for it I take medication for my cholesterol and this keeps it in the normal range I think my cholesterol has always been OK I have no idea what my cholesterol levels are

How much activity do you get in the average week? Minimal activity such as walking around the house and shopping slowly Light activity such as walking a half of a block or going shopping briskly Moderate activity such as walking or riding a bike for 20-30 minutes once or twice a week High-moderate activity like 30 minutes of hiking, brisk walking or swimming more than twice a week Vigorous activity such as over 30 minutes of high intensity exercise like running and stair climbing more than twice a week

Which statement best describes your diabetic diet? I don't really watch my diet much. I rarely eat high-fiber foods like fruits, vegetables and whole grain, and I frequently eat foods that are sweet, sugary and/or fried. I try to watch my diet, but only occasionally eat high-fiber foods. I do eat more sweets and/or fried foods than I should. I'd say my diet is about average. I eat some high-fiber foods every day but not a lot. I do eat some sweets and/or fried foods. My diet is good. I eat lots of fruits, vegetables and whole grains and few fried foods or sweets.

Which statement best describes your tobacco use? I have smoked one or more packs of cigarettes per day for over 20 years I have smoked one or more packs of cigarettes per day for less than 20 years I have smoked less than one pack of cigarettes per day for over 20 years I have smoked less than one pack of cigarettes per day for less than 20 years I quit smoking less than 5 years ago I quit smoking 5 to 10 years ago I quit smoking over 10 years ago I have never smoked cigarettes

When was your last urine protein check (microalbumin)? 3 months ago 6 months ago 12 months ago I don't know

When was the last time you had your eyes checked by an ophthalmologist? 3 months ago 6 months ago 12 months ago I don't know

When was the last time you had a foot exam with a doctor? 3 months ago 6 months ago 12 months ago I don't know

When was your last Flu shot? 3 months ago 6 months ago 12 months ago I don't know