Diabetes Risk Assessment Test

Diabetes Risk Assessment Test (당뇨 위험도 검사)
Name*
First Last
이름 (한글)
Birth Date (생년월일)*
MM slash DD slash YYYY
Sex (성별)*
- Male (남)
- Female (여)
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
History of Diabetes (당뇨병력)
당뇨병이 ...*
- 있다
- 없다
- 잘 모른다
당뇨병이 있으며 ...
- 약을 복용하고 있다
- 약을 복용하지 않는다
혈액검사 권유를 ...*
- 받았다
- 받은 적 없다
초기당뇨가 ...*
- 있다
- 없다
영양식단 교육을 언급 ...*
- 받았다
- 받은 적 없다
당뇨와 관련해 의사 진료를 ...*
- 받은 적 있다
- 받은 적 없다
Diabetes Risk (당뇨 위험도)
I am 65 years old or older (나이가 65 세이상 입니다)*
- Yes (예)
- No (아니오)
I am between 45 and 64 years of age (나이가 45세에서 64세사이 입니다)*
- Yes (예)
- No (아니오)
I am under 65 years of age and I get little or no exercise during a usual day (나이가 65세이하로 운동을 안합니다. 주 3일 30분이상)*
- Yes (예)
- No (아니오)
My weight is equal to or above that listed in the next chart (체중이 신장에 비해서 아래에 도표와 같거나 높습니다)*
- Yes (예)
- No (아니오)
At Risk Weight Chart

Height (신장)	Weight (체중)
4’ 10” (147 cm)	129 Lbs (58 Kg)
5’ 0” (152 cm)	138 Lbs (62 Kg)
5’ 1” (155 cm)	143 Lbs (64 Kg)
5’ 2” (157 cm)	147 Lbs (66 Kg)
5’ 3” (160 cm)	152 Lbs (68 Kg)
5’ 4” (163 cm)	157 Lbs (71 Kg)
5’ 5” (165 cm)	162 Lbs (73 Kg)
5’ 6” (168 cm)	167 Lbs (75 Kg)
5’ 7” (170 cm)	172 Lbs (77 Kg)
5’ 8” (173 cm)	177 Lbs (80 Kg)
5’ 9” (175 cm)	182 Lbs (82 Kg)
5’ 10” (178 cm)	188 Lbs (85 Kg)
5’ 11” (180 cm)	193 Lbs (87 Kg)
6’ 0” (183 cm)	199 Lbs (90 Kg)
6’ 1” (185 cm)	204 Lbs (92 Kg)
6’ 2” (188 cm)	210 Lbs (95 Kg)
6’ 3” (191 cm)	216 Lbs (97 Kg)
6’ 4” (193 cm)	221 Lbs (99 Kg)

I have a sister or brother with diabetes (형재중에 당뇨병이 있습니다)*
- Yes (예)
- No (아니오)
I have a parent with diabetes (부모가 당뇨병이 있습니다)*
- Yes (예)
- No (아니오)
I am a woman who has had a baby weighing more than nine pounds at birth (여자로 신생아 체중이 9 파운드 넘는 자녀가 있습니다)*
- Yes (예)
- No (아니오)
Comments
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Our Mission

The KCC’s Mission is to promote healthy and independent living for all ages and to integrate the people with Korean Heritage into the greater community through culture & education, outreach, health & social services, and civic advocacy.

KCC Gallery

Curator: Christine Seo
E-mail: gallery@kccus.org
T. 201-541-1200 ext.111

Contact Info

Korean Community Center
100 Grove Street
Tenafly, NJ 07670

NJ Transit Bus 166
Rockland Coach Bus 14E

Phone : 201-541-1200
Fax : 201-541-4060
www.kccus.org

Make Korean-Americans Proud

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Diabetes Risk Assessment Test

Diabetes Risk Assessment Test (당뇨 위험도 검사)

History of Diabetes (당뇨병력)

Diabetes Risk (당뇨 위험도)

At Risk Weight Chart