HabitNu and Harrisburg IPhA

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Presented in partnership with

Funding for this program is provided by the Illinois Department of Public Health’s grant: Improving the Health of Illinoisans Through Chronic Disease Prevention (CDC-DP18-1815)
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How young are you?* This field is required.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
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Were you born male or female?* This field is required. Your genes can make a difference.
MaleFemale
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Have you been diagnosed with gestational diabetes in the past?* This field is required.This is defined as high blood sugar during pregnancy.
YESNO
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Are you currently pregnant?* This field is required.
YESNO
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Have you been diagnosed with diabetes?* This field is required.
Type 1 Diabetes
Type 2 Diabetes
Pre-diabetes
Not diagnosed with diabetes
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Was prediabetes diagnosed by blood glucose test?* This field is required.
YESNO
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Do you know your most recent A1c?* This field is required.
YESNO
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What was your most recent A1c?* This field is required.Please leave this blank and continue to the next question if you are unsure or do not know your A1c.
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Do you know your most recent fasting glucose?* This field is required.
YESNO
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What was your most recent fasting glucose?* This field is required.
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Do you have a family member with type 2 diabetes?* This field is required. Diabetes can be hereditary!
YESNO
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Have you ever been diagnosed with high blood pressure?* This field is required. Having high blood pressure contributes to your overall risk for type 2 diabetes.
YESNO
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Are you physically active?* This field is required.
YESNO
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How tall are you?* This field is required.
Feet
Inches
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How much do you weigh?* This field is required.
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Please tell us your ethnicity* This field is required.
Hispanic or Latino
Non-Hispanic or Latino
Unknown
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Please tell us your race.* This field is required.Choose all that apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other/Prefer not to say
Unknown
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Score
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Race
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Program
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BMI
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Insurance
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Custom Text
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RaceMapValue
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EthnicityMapValue
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Education
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Referral Source
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Bloodwork is OK
YESNO
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A1c is OK
YESNO
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Glucose is OK
YESNO
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Asian BMI is OK
YESNO
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BMI is OK
YESNO
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Eligible for CDC
YESNO
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Home URL
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Weight Class
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Tags
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Todays date
Date
Year
Month
Day
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Hour
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Minutes
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Based on your answers, you are not at risk for type 2 diabetes

However you can join the program to lose weight

Please answer the next few questions so we may complete your registration.
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You are eligible to participate!

Based on your responses, our CDC- recognized Diabetes Prevention Program is one of the most effective ways to reduce your risk of going on to develop Type 2 Diabetes. This program is a full year in length and helps you to make lifestyle changes slowly until those changes become habit

Next, we’ll ask for your contact details to register you for our program.
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HIPAA Patient Consent* This field is required.In order to start the start the process you must give consent to participate in the HabitNu Diabetes Prevention Program.
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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Mobile* This field is required.
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Address* 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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
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
Curaçao
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
United States
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
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Timezone* This field is required.What timezone are you in?
Eastern
Central
Mountain
Pacific
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Date of Birth* This field is required.
Month
Day
Year
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Please tell us about your health insurance* This field is required.
I am an employee covered by Hope Trust
I am a dependent covered by Hope Trust
I have a different insurance plan not covered by Hope Trust
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How did you learn about this class?
Non-primary healthcare professional
Primary care provider
Community health worker/organization
Self-driven
Family/Friends
Employer
Insurance Company
National Media (TV, Radio, Internet Ad, Newspaper, Etc.)
Social Media (Facebook, Twitter, Etc.)
Pharmacist
Diabetes Educator
Other
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I eat healthyThe following questions pertain to where you are right now with regards to eating habits. Answer each by selecting the option that best identifies how you feel with each statement. Select Not Sure if you either do not want to answer the question or if you don’t know the answer.
Strongly Agree
Agree
Disagree
Strongly Disagree
Not Sure
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I want to eat more healthyThe following questions pertain to where you are right now with regards to eating habits. Answer each by selecting the option that best identifies how you feel with each statement. Select Not Sure if you either do not want to answer the question or if you don’t know the answer.
Strongly Agree
Agree
Disagree
Strongly Disagree
Not Sure
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I get enough physical activityThe following questions pertain to where you are right now with regards to exercise habits. Answer each by selecting the option that best identifies how you feel about each statement. Select Not Sure if you either do not want to answer the question or if you don’t know the answer.
Strongly Agree
Agree
Disagree
Strongly Disagree
Not Sure
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I want to be more physically activeThe following questions pertain to where you are right now with regards to exercise habits. Answer each by selecting the option that best identifies how you feel about each statement. Select Not Sure if you either do not want to answer the question or if you don’t know the answer.
Strongly Agree
Agree
Disagree
Strongly Disagree
Not Sure
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Are you confident in your ability to get physically active more often?In order to reduce your risk of going on to develop diabetes, you will likely need to change eating, exercise and lifestyle habits. Select the option that indicates how confident you are with the following changes.
I sure can!
I think I can!
I’m not sure
I don’t think I can
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Are you confident in your ability to increase the length of time you can be physically active?In order to reduce your risk of going on to develop diabetes, you will likely need to change eating, exercise and lifestyle habits. Select the option that indicates how confident you are with the following changes.
I sure can!
I think I can!
I’m not sure
I don’t think I can
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Are you confident in your ability to eat more healthy food?In order to reduce your risk of going on to develop diabetes, you will likely need to change eating, exercise and lifestyle habits. Select the option that indicates how confident you are with the following changes.
I sure can!
I think I can!
I’m not sure
I don’t think I can
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Are you confident in your ability to over-eat less often?In order to reduce your risk of going on to develop diabetes, you will likely need to change eating, exercise and lifestyle habits. Select the option that indicates how confident you are with the following changes.
I sure can!
I think I can!
I’m not sure
I don’t think I can
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Comfortability with technologySuch as: Computer, Smart Phone, Tablets, etc.
Very Comfortable
Comfortable
Not Comfortable
Cannot Use
How comfortable are you with using technology?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
How comfortable are you with using technology?
Very Comfortable
Row 0, Column 0
Comfortable
Row 0, Column 1
Not Comfortable
Row 0, Column 2
Cannot Use
Row 0, Column 3
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How do you typically access the internet?This program is delivered online through live meetings and habit building tools accessed through an app on a smartphone or tablet.
Phone
Computer or laptop
Tablet
Home network
Public location
Data Plan
Friend or family device
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Internet reliability Internet access is important because this program is done online.
Unreliable
Slow but usable
Reliable
Always on, fast
How reliable is your internet?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
How reliable is your internet?
Unreliable
Row 0, Column 0
Slow but usable
Row 0, Column 1
Reliable
Row 0, Column 2
Always on, fast
Row 0, Column 3
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Do you have challenges with access to healthy food?
YESNO
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Do you have challenges accessing transportation?
YESNO
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Do you have challenges accessing childcare?
YESNO
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What is your household income?
below $20,000
$20,000 to $50,000
$50,000 to $80,000
$80,000 to $125,000
$125,000 to $160,000
more than $160,000
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Highest grade or year of school completed?
Less than grade 12
High School Graduate
Some College or Technical School
College Graduate
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How busy is your weekly work schedule?Please list weekly hours below.
Very Busy
Busy
Not Busy
Open Schedule
Other
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What time of the day is best for you to participate in meetings?
Morning
Afternoon
Evening
Anytime
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Desired class time and date.When would you like to have your first class?
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Thank you for registering!

You have begun your journey to better health.

Congratulations, you are now registered in HOPE Trust’s Lifestyle Change Program. Please watch for an email from our partners, HabitNu that will have more and steps that you should take before the first session. Please ask your provider for the full set of meeting dates and a brochure that you can take with you.

You will be taken back to the "HOPE Trust" homepage now.
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Thank you for participating

Based on your previous answers you are not eligible to enroll at this time.

You will be taken back to the "HOPE Trust" homepage now.
Should be Empty:

Based on your answers, you are not at risk for type 2 diabetes

You are eligible to participate!