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Have you ever had a foot ulcer?
Yes
No
How long have you been diagnosed with diabetes?
Less than 1 year
1-5 years
6-10 years
More than 10 years
Have you experienced numbness or tingling in your feet, or a reduced ability to feel pain or pressure?
Yes
No
How physically active are you? (walking, running, hiking)
Not at all (little or no excercise)
Lightly active (1-3 days / week)
Moderately active (3-5 days / week)
Very active (6-7 days / week)
Have you noticed any of these symptoms: leg cramps, shiny and cool skin, brittle nails?
Yes
No
How old are you?
18-35
36-50
51-65
65+
What is your height and weight?
Imperial
Metric
Height
lb
kg
Weight
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