HabitNu and MO DHSS

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How young are you?* This field is required.Question 1 of 10 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.Question 2 of 10 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?Question 3 of 10
Type 1 Diabetes
Type 2 Diabetes
Pre-diabetes
Not diagnosed with diabetes
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Do you have a family member with type 2 diabetes?* This field is required.Question 4 of 10 Diabetes can be hereditary!
YESNO
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Have you ever been diagnosed with high blood pressure?* This field is required.Question 5 of 10 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.Question 6 of 10
YESNO
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How tall are you?* This field is required.Question 7 of 10
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.Question 10 of 10
Hispanic or Latino
Non-Hispanic or Latino
Unknown
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Please tell us your race.* This field is required.Question 9 of 10 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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ReadinessScore
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Race
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Program
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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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Home URL
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BMI
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Asian BMI is OK
YESNO
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Weight Class
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BMI is OK
YESNO
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Tags
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Todays date
Date
Year
Month
Day
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Hour
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50
Minutes
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Location
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Based on your answers, you are not at risk for type 2 diabetes

However you can join HabitNu 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 HabitNu lifestyle change program is one of the most effective ways to lose weight and prevent the onset of type 2 diabetes.

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.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.
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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
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
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Iowa
Kansas
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Louisiana
Maine
Maryland
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Tennessee
Texas
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Virgin Islands
Virginia
Washington
West Virginia
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Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
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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
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Djibouti
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Dominican Republic
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Faroe Islands
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The Gambia
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Guinea
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Hungary
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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
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Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
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Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
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New Caledonia
New Zealand
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Nigeria
Niue
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Northern Mariana
Norway
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Paraguay
Peru
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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
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Saint Vincent and the Grenadines
Samoa
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Saudi Arabia
Senegal
Serbia
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Somalia
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South Ossetia
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eSwatini
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Other
Country
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Date of Birth* This field is required.
Month
Day
Year
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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 Medicaid plans. If you do not have one of these plans we will contact you later for your insurance information.
Medicare
Medicaid
Medicare Advantage
None of these
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Medicare or Medicaid Number
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Group Number
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Member ID
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Where did you learn about this program?
Community Event
Postcards or Flyers in the Community
Website
Email Promotion Form
Community Health Worker (CHW) or Community Referral Coordinator (CRC)
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Thinking back across the past three months, select the option that indicates how strongly you agree or disagree with the statements:
Strongly Disagree
Disagree
Agree
Strongly Agree
Not Sure
"I eat healthy"
"I want to eat more healthy"
"I get enough physical activity"
"I want to be more physically active"
"I eat healthy"
"I want to eat more healthy"
"I get enough physical activity"
"I want to be more physically active"
Strongly Disagree
Disagree
Agree
Strongly Agree
Not Sure
Strongly Disagree
Disagree
Agree
Strongly Agree
Not Sure
Strongly Disagree
Disagree
Agree
Strongly Agree
Not Sure
Strongly Disagree
Disagree
Agree
Strongly Agree
Not Sure
1 of 4
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Select the option that indicates how strongly you agree or disagree with the statements today:Are you confident in your ability...
I sure can!
I think I can
I'm not sure
I don't think I can
Are you confident in your ability to get physically active more often?
Are you confident in your ability to increase the length of time you can be physically active?
Are you confident in your ability to eat more healthy food?
Are you confident in your ability to over-eat less often?
Are you confident in your ability to get physically active more often?
Are you confident in your ability to increase the length of time you can be physically active?
Are you confident in your ability to eat more healthy food?
Are you confident in your ability to over-eat less often?
I sure can!
I think I can
I'm not sure
I don't think I can
I sure can!
I think I can
I'm not sure
I don't think I can
I sure can!
I think I can
I'm not sure
I don't think I can
I sure can!
I think I can
I'm not sure
I don't think I can
1 of 4
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How do you access the internet?Check all that apply
Phone
Computer or laptop
Tablet
Home network
Public location
Data Plan
Friend or family device
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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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Thank you for registering!

You have begun your journey to better health.

You are registered as a new participant. You will receive an email with instructions to help you set up your account and download the HabitNu App.

Once your account is set up, you will be ready to get started. Your digital scale will be ordered and shipped to the address on file. You can expect to receive it in 7 to 10 days.

Your lifestyle coach will be in touch with you in the next few days!
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Thank you for your interest in joining the HabitNu Diabetes Prevention Program (DPP).

Unfortunately, this program is best suited for people who are pre-diabetic rather than already diagnosed. The good news – You may be eligible for a different lifestyle change program for free!

A MO DHSS outreach team member will follow up with you at the phone number or email you provided to help you determine which option is best for you. If you have questions in the mean-time, please contact the MO DHSS outreach team at 312-566-7871 or support@habitnu.com.
Should be Empty:

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

You are eligible to participate!