Mid Cumberland Quiz

1
Are you physically active?* This field is required.
YESNO
2
How tall are you?* This field is required.
Feet
Inches
3
Date of Birth* This field is required.You must be at least 18 years old to take part in this program.
Month
Day
Year
4
How much do you weigh?* This field is required.
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
Have you been diagnosed with diabetes?* This field is required.Diabetes can be hereditary!
Type 1 Diabetes
Type 2 Diabetes
Pre-diabetes
Not diagnosed with diabetes or prediabetics
I don't know
8
Was prediabetes diagnosed by blood glucose test?* This field is required.
YESNO
9
What was your most recent A1c?
10
What was your most recent fasting glucose?
11
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
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
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.The DPP program is not recommended during pregnancy.
YESNO
16
Program
17
UserProgramId
18
Race
19
Score
20
ReadinessScore
21
Weight Class
22
RaceMapValue
23
Education
24
Referral Source
25
Enrollment Source
26
Eligible for CDC
YESNO
27
Tech Challenge Score
28
BMI
29
Bloodwork is OK
YESNO
30
A1c is OK
YESNO
31
Glucose is OK
YESNO
32
Asian BMI is OK
YESNO
33
User Wants Aid
YESNO
34
BMI is OK
YESNO
35
Todays date
Date
Year
Month
Day
36
days since 18th bday
37
Age
38
Age Points
39
Kickout Card
40
Insurance
41
CDC Points
42

Thank you for completing the risk test!

Based on your answers, you are not currently eligible for this program.
If you have any questions, please contact your regional health department.

Rutherford County: 615-806-2135

Montgomery County: 615-762-0236

Sumner county: 615-206-1100

Stewart County 931-232-5329
43

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.
44
Would you like to register for the HabitNu program?* This field is required.
YES, I'd love toNO, not today
45
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.
46
At which location would you prefer to attend an in person class?* This field is required.
Sumner County Health Dept.1005 Union School RD Gallatin, TN 37066-2084
Stewart County Community Health 1021 Spring St. Dover, TN 37058-0497
Rutherford County Health Dept. 100 West Burton Murfreesboro, TN 37130-3657
Montgomery County Health Dept. 330 Pageant Lane PO Box 1026 Clarksville, TN 37401-1026
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
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California
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Ohio
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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
Zip Code* This field is required.
52
Timezone* This field is required.
Central
Eastern
Mountain
Pacific
53
Thank you for participating!

We are sorry, you are ineligible to participate.

We are only conducting in-person classes located within the central time zone.
54
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.)
55
Did any of these people recommend this program?
Yes, a doctor/doctor’s office
Yes, a pharmacist
Yes, other healthcare professional
No
56
Highest grade or year of school completed?
Less than grade 12
High School Graduate
Some College or Technical School
College Graduate
57
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, I want to share more!NO, let me exit please.
58
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
59
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
60
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
61
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
62
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
63
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
64
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
65
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
66
Are you comfortable using smartphones, laptops, tablets, and apps?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
67
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
Tablet
Public location
Friend or family device
Computer or laptop
Home network
Data plan
At work
68
How reliable is your Internet connection?Internet access is important because this program is done online.
Always on, fast
Reliable
Slow, but usable
Unreliable
69
Do you have challenges with access to healthy food?
YESNO
70
Do you have challenges accessing transportation?
YESNO
71
Do you have challenges accessing childcare?
YESNO
72
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
73
Thank you for registering!

You have begun your journey to better health.

Congratulations, you are now registered in the HabitNu Platform with the Public Health Department conducting the sessions. Please watch for an email from HabitNu that will have more information about the in -person or virtual program start date with the Coaches from the Health Department.
74
Thank you for participating!

If you have any questions, please contact your regional health department.

Rutherford County 615-806-2135

Montgomery County 615-762-0236

Sumner county 615-206-1100

Stewart County 931-232-5329
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