St Louis Enrollment Quiz

1
Have you been diagnosed with diabetes?* This field is required.
Type 1 Diabetes
Type 2 Diabetes
Pre-diabetes
Not diagnosed with diabetes or prediabetics
I don't know
2
Was prediabetes diagnosed by blood glucose test?* This field is required.
YESNO
3
What was your most recent A1c?
4
What was your most recent fasting glucose?
5
Do you have a family member with type 2 diabetes?* This field is required.Diabetes can be hereditary!
YESNO
6
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
7
Date of Birth* This field is required.You must be at least 18 years old to take part in this program.
Month
Day
Year
8
What is your race or ethnicity? Select ALL that apply. You may enter additional details in the space below.* This field is required.Some race/ethnic minorities have a higher prevalence of diabetes.
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
Other
9
Are you physically active?* This field is required.
YESNO
10
How tall are you?* This field is required.
Feet
Inches
11
How much do you weigh?* This field is required.
12
Were you born male or female?* This field is required.Your genes can make a difference.
MaleFemale
13
How do you currently identify?* This field is required.
Male
Female
Transgender male
Transgender female
Not listed
Prefer not to answer
14
Have you been diagnosed with gestational diabetes in the past?* This field is required.This is defined as high blood sugar during pregnancy.
YESNO
15
Are you currently pregnant?* This field is required.
YESNO
16
Program
17
Race
18
Score
19
ReadinessScore
20
Weight Class
21
Diabetic patient email
example@example.com
22
EthnicityMapValue
23
RaceMapValue
24
Education
25
Referral Source
26
Enrollment Source
27
Eligible for CDC
YESNO
28
Tech Challenge Score
29
BMI
30
Bloodwork is OK
YESNO
31
A1c is OK
YESNO
32
Glucose is OK
YESNO
33
Asian BMI is OK
YESNO
34
User Wants Aid
YESNO
35
BMI is OK
YESNO
36
Todays date
Date
Year
Month
Day
37
days since 18th bday
38
Kickout Card
39
Age
40
Age Points
41
Insurance
42
CDC Points
43

Thank you for completing the risk test!

Based on your answers, you are not currently eligible for this progam.

If you have any questions, please contact us at (123)456-7891
44

You are eligible to participate!

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.
45
Would you like to register for the HabitNu program?* This field is required.
YES, I'd love toNO, not today
46
HIPAA Patient Consent* This field is required.In order to start the process you must give consent to participate in the HabitNu Diabetes Prevention Program.
47
Name* This field is required.
First Name
Last Name
48
Email* This field is required.
example@example.com
49
Mobile* This field is required.
50
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
51
Timezone* This field is required.
Eastern
Central
Mountain
Pacific
52
How did you learn about this class?* This field is required.
Health care professional
Blood test results
Prediabetes risk test (short survey)
Someone at a communitybased organization (church, community center, fitness center)
Family or friends
Current or past participant in the National DPP LCP
Employer or employer’s wellness plan
Health insurance plan
Media advertisements (social media, flyer, brochure, radio ad, billboard, etc.)
Community Health Worker
53
Did any of these people recommend this program?* This field is required.
Yes, a doctor/doctor’s office
Yes, a pharmacist
Yes, other healthcare professional
No
54
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. If your plan is not listed here then you may still purchase the program, out-of-pocket for $35/mo for 12 months
Medicare
Medicaid
Medicare Advantage
Commercial
Self-pay
No insurance at this time
Unknown
55
Medicare or Medicaid number* This field is required.Your Medicare/Medicaid Number is shown on the front of your Medicare or Medicaid card.
56
Please select your Medicare Advantage plan* This field is required.
1199 National Benefit Fund
AARP
Aetna
Aetna Better Health of Illinois
AR BCBS
Blue Cross Community Options
Boncura Health Solutions
CIGNA
Clear Spring Health of Illinois
Essence Healthcare
Harmony Health Plan of Illinois
HCH Administration Illinois
Humana
IL BCBS
IL Fornaio (America) Corp
IL Medicaid
IlliniCare
Longevity Illinois
Meridian Health Plan Illinois
Provider Partners Health Plan Illinois
Sunrise Advantage Plan of Illinois
United Health Care
Wellcare
My plan is not listed
57
Group numberThis may also be called "Plan", "Plan Number" or abbreviated as "GRP" on your insurance card.
58
Member ID* This field is required.This may be called "Policy Number" or just "ID" on your insurance card.
59
Insurance Company Name
60
Please help us get to know you better* This field is required.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, I want to share more!NO, let me exit please
61
What are your habits?The following questions pertain to where you are right now with regards to eating. 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.
I eat healthy
I want to eat more healthy
Not Sure
62
What are your habits?The 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 with each statement. Select Not Sure if you either do not want to answer the question or if you don’t know the answer.
I get enough physical activity
I want to be more physically active
Not Sure
63
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:
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly Agree
64
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:
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly Agree
65
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:
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly Agree
66
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:
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly Agree
67
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).
Very Comfortable
Comfortable
Uncomfortable
Cannot Use
Are you comfortable using smartphones, laptops, tablets, and apps?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Are you comfortable using smartphones, laptops, tablets, and apps?
Very Comfortable
Row 0, Column 0
Comfortable
Row 0, Column 1
Uncomfortable
Row 0, Column 2
Cannot Use
Row 0, Column 3
68
How do you typically access the internet?* This field is required.This program is delivered online through live meetings and habit building tools accessed through an app on a smartphone or tablet.
Phone
Tablet
Public location
Friend or family device
Computer or laptop
Home network
Data plan
At work
No access
69
How reliable is your Internet connection?Internet access is important because this program is done online.
Always on, fast
Reliable
Slow, but usable
Unreliable
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?
Always on, fast
Row 0, Column 0
Reliable
Row 0, Column 1
Slow, but usable
Row 0, Column 2
Unreliable
Row 0, Column 3
70
Do you have challenges with access to healthy food?* This field is required.
YESNO
71
Do you have challenges accessing transportation?* This field is required.
YESNO
72
Do you have challenges accessing childcare?* This field is required.
YESNO
73
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
Prefer not to disclose
74
Highest grade or year of school completed?
Less than grade 12
High School Graduate
Some College or Technical School
College Graduate
75
Do you have a preference for class day?Please select all options that apply
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
76
Do you have a preference for class time?Please select all options that apply
Morning
Afternoon
Evening
77
Thank you!

Congratulations, you have begun your journey to better health.

You are now registered in the HabitNu Program. Please watch for an email from HabitNu that will have more information about the program start date.
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