Are you physically active?* This field is required.Question 1 of 10

YESNO

How tall are you?* This field is required.Question 2 of 10

Feet

Inches

How much do you weigh?* This field is required.Question 3 of 10

Date of Birth* This field is required.Question 4 of 10 You must be at least 18 years old to take part in this program.

Were you born male or female?* This field is required.Question 5 of 10 Your genes can make a difference.

MaleFemale

Have you been diagnosed with gestational diabetes in the past?* This field is required.This is defined as high blood sugar during pregnancy.

YESNO

Have you been diagnosed with diabetes?* This field is required.Question 6 of 10

Type 1 Diabetes

Type 2 Diabetes

Pre-diabetes

Not diagnosed with diabetes or prediabetes

I don't know

Do you have a family member with type 2 diabetes?* This field is required.Question 7 of 10 Diabetes can be hereditary!

YESNO

Have you ever been diagnosed with high blood pressure?* This field is required.Question 8 of 10 Having high blood pressure contributes to your overall risk for type 2 diabetes.

YESNO

Please tell us your ethnicity* This field is required.Question 9 of 10 People of South American (Latino) descent have a higher risk for type 2 diabetes.

Hispanic or Latino

Non-Hispanic or Latino

Unknown

Please tell us your race.* This field is required.Some race/ethnic minorities have a higher prevalence of diabetes.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other/Prefer not to say

Unknown

Do you have any of these conditions?Question 10 of 10 Our program is not suitable for anyone with one of these conditions: • Pregnant or breastfeeding • Major surgery in the last 3 months (chest, abdominal or cancer surgery) • Undergoing chemo or radiation therapy for cancer • Experienced a heart attack or stroke within the last six months • Kidney disease currently requiring dialysis or special diet • Diagnosed with or actively seeking treatment for an eating disorder • Undergone bariatric surgery within the last three months • Currently struggling with a significant mental disorder Do you have any of these conditions?

YESNO

Thank you for your interest in our program

Based on your previous answers you are not eligible to enroll at this time. Please consult with your physician and retake the assessment if anything should change.

Please visit your closest Walmart Health clinic to learn more!

www.walmarthealth.com

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EthnicityMapValue

Tech Challenge Score

Dummy name

First Name

Last Name

Dummy mobile

Area Code

Phone Number

Todays date

Date

Hour

Minutes

You already have diabetes

However, you can still join HabitNu to learn healthy eating habits, get moving, and lose weight.

Please continue to complete your registration.

The good news is you are at low risk for developing type 2 diabetes!

You can join HabitNu to learn healthy eating habits, get moving, and lose weight.

Please continue to complete your registration.

You are eligible to participate!

Based on your responses, HabitNu's CDC-recognized program is one of the most effective ways to reduce your risk of developing type 2 diabetes. This year-long program helps you make sustainable lifestyle changes, lose weight, and keep it off.

Please continue to complete your registration

HIPAA Patient Consent* This field is required.Please give your consent to participate in the HabitNu Program.

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Mobile* This field is required.

Timezone* This field is required.We use this information to assign you to a class that meets at an appropriate time.

Eastern

Central

Mountain

Pacific

If you have health insurance, choose the option that best matches you* This field is required.HabitNu is a covered benefit for Medicare, Medicare Advantage and BCBS AK plans. If you do not have one of these plans you will have the opportunity to self-pay for the program.

Medicare

Medicare Advantage

I am a Walmart associate with BCBS AK

Self-pay

No insurance at this time (self-pay)

If you are a Walmart Associate, what is your store number?

Your health plan does not cover the HabitNu program.* This field is required.However, you may still join by choosing the self-pay option at $35/month.

Self-payNot now

Thank you for your interest in our program

If you change your mind and would like to choose the self-pay option, please return and take the quiz again. Please visit your closest Walmart Health clinic to learn more!

www.walmarthealth.com

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Self-pay Subscription * This field is required.

HabitNu Program for Walmart Health
$35.00 for each month
SUBSCRIBE

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please help us get to know you better...* This field is required.If you have a few minutes to spare, please answer a few more questions. This will help us tailor the program to better meet the needs of our users.

YES, please continueNO, let me exit please

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.)

What are your habits?The following questions pertain to where you are right now with regards to eating and exercise 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.

How confident are you today?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:

How comfortable are you with technology?This program is delivered online through live meetings and habit-building tools accessed through an app on a smartphone or tablet (or through a web browser). If you are not comfortable using a smar

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

At work

How reliable is your Internet connection? Internet access is important because this program is done online.

Highest grade or year of school completed?

Less than grade 12

High School Graduate

Some College or Technical School

College Graduate

What is your desired class time?

Morning

Afternoon

Evening

Thank you for enrolling!

Your coach will call you in a week to get you started. Be sure to check your email to download your HabitNu app and set up your profile to get started today!

We are excited to be with you on your journey to learn how small lifestyle changes can help you live a healthier life!

www.walmarthealth.com

You will be taken back to the homepage now.