HabitNu and Community Health Innovations

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How young are you?* This field is required.Question 1 of 9 You must be at least 18 years old to take part in this program.
Younger than 40
40-49 Years
50-59 Years
60 and older
2
Were you born male or female?* This field is required.Question 2 of 9 Your genes can make a difference.
MaleFemale
3
Have you been diagnosed with gestational diabetes in the past?* This field is required.This is defined as high blood sugar during pregnancy.
YESNO
4
Are you currently pregnant?* This field is required.The HabitNu program is not recommended during pregnancy.
YESNO
5
Have you been diagnosed with diabetes?Question 3 of 9
Yes, type 1 diabetes
Yes, type 2 diabetes
No, but yes for pre-diabetes
No diabetes diagnosis
6
Do you have a family member with type 2 diabetes?* This field is required.Question 4 of 9
YESNO
7
Have you ever been diagnosed with high blood pressure?* This field is required.Question 5 of 9 Having high blood pressure contributes to your overall risk for type 2 diabetes.
YESNO
8
Are you physically active?* This field is required.Question 6 of 9
YESNO
9
Please tell us your ethnicity/race.* This field is required.Question 7 of 9 People of certain racial and ethnic groups are more likely to develop type 2 diabetes than others. Choose all that apply
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other/Prefer not to say
10
How tall are you?* This field is required.Question 8 of 9 Please use whole numbers here, do not use a decimal point in these fields.
Feet
Inches
11
How much do you weigh?Question 9 of 9
less than 119
119-142
143-190
more than 190
12
How much do you weigh?Question 9 of 9
less than 124
124-147
148-197
more than 197
13
How much do you weigh?Question 9 of 9
less than 132
132-157
158-210
more than 210
14
How much do you weigh? Question 9 of 9
less than 136
136-163
164-217
more than 217
15
How much do you weigh? Question 9 of 9
less than 141
141-168
169-224
more than 224
16
How much do you weigh?Question 9 of 9
less than 145
145-173
174-231
more than 231
17
How much do you weigh? Question 9 of 9
less than 150
150-179
180-239
more than 239
18
How much do you weigh? Question 9 of 9
less than 155
155-185
186-246
more than 246
19
How much do you weigh? Question 9 of 9
less than 128
128-152
153-203
more than 203
20
How much do you weigh?Question 9 of 9
less than 159
159-190
191-254
more than 254
21
How much do you weigh? Question 9 of 9
less than 164
164-196
197-261
more than 261
22
How much do you weigh? Question 9 of 9
less than 169
169-202
203-269
more than 269
23
How much do you weigh? Question 9 of 9
less than 174
174-208
209-277
more than 277
24
How much do you weigh?Question 9 of 9
less than 179
179-214
215-285
more than 286
25
How much do you weigh? Question 9 of 9
less than 184
184-220
221-293
more than 293
26
How much do you weigh?Question 9 of 9
less than 189
189-226
227-301
more than 301
27
How much do you weigh?Question 9 of 9
less than 194
194-232
233-310
more than 310
28
How much do you weigh? Question 9 of 9
less than 200
200-239
240-318
more than 318
29
How much do you weigh? Question 9 of 9
less than 205
205-245
246-327
more than 327
30
Score
31
Ethnicity
32
Program
33
Tags
34

Your risk is low for type 2 diabetes

With education and lifestyle changes, diabetes can be prevented or delayed and some of its more serious complications avoided.

Community Health Innovations is leading the effort to reduce diabetes in Monterey County by offering personalized programs that help support everyday healthy living.

For more information, please call us at (831) 644-7490.
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You are eligible to participate!

With education and lifestyle changes, diabetes can be prevented or delayed and some of its more serious complications avoided.

Community Health Innovations is leading the effort to reduce diabetes in Monterey County by offering personalized programs that help support everyday healthy living.

For more information, please call us at (831) 644-7490.
36
Let's get registered.

In the next few pages we will gather the contact information necessary to register you in the program, as well as ask a few questions about healthcare insurance.

First we'll ask your consent to collect and protect your private information. This is the standard HIPAA Privacy form you typically sign when you visit the doctor.
37
HIPAA Patient Consent* This field is required.You must give your consent to participate in the HabitNu Diabetes Prevention Program. If you do not consent, please navigate away from this page now.
38
Name* This field is required.
First Name
Last Name
39
Email* This field is required.
example@example.com
40
Mobile* This field is required.
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Location* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
42
Date of Birth* This field is required.
Month
Day
Year
43
Please tell us about your health insurance* This field is required.HabitNu is a covered benefit for Medicare, Medicare Advantage, and some commercial insurance plans.
Medicare
Aspire Medicare Advantage
Anthem California
Other insurance
No insurance at this time
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No insurance? We've got you covered.

Community Health Innovations has scholarships available for qualified individuals.

Please call us at (831) 644-7490 for more information.
45
Medicare numberHabitNu is a fully covered medical benefit for Medicare members. Your Medicare Number is shown on the front of your Medicare card. This field is required to check your eligibility.
46
Who is your healthcare insurance company?* This field is required.HabitNu is a covered medical benefit for Medicare Advantage members and for some commercial insurance plans. In the questions to follow, provide as much information as you can (you can find this information on your insurance card).
47
Insurance planThe plan name can be hard to find on your insurance card. Sometimes the plan is labelled "Medical Network", or "Health Plan", or is the name of your company. If you can't find it, leave this field blank.
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Group NumberThis may also be called "Plan", "Plan Number" or abbreviated as "GRP". If you can’t find this, leave it blank.
49
Member IDThis may be called "Policy Number" or just "ID". If you can’t find this, leave it blank.
50
Healthcare provider's phone numberYour insurance card should have this phone number on it, often located on the back of the card. if you don't have it, just leave this field blank.
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You're all done! You have begun your journey to better health!

Community Health Innovations will contact you within 72 hours to schedule your classes.

For more information call (831) 644-7490.

Welcome to HabitNu.
Should be Empty:

Your risk is low for type 2 diabetes

You are eligible to participate!