IPhA Enrollment 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.
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
Please tell us your ethnicity* This field is required.People of South American (Latino) descent have a higher risk for type 2 diabetes.
Hispanic or Latino
Non-Hispanic or Latino
Unknown
12
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
13
Were you born male or female?* This field is required.Your genes can make a difference.
MaleFemale
14
How do you currently identify?* This field is required.
Male
Female
Transgender
Prefer not to say
15
Have you been diagnosed with gestational diabetes in the past?* This field is required.This is defined as high blood sugar during pregnancy.
YESNO
16
Are you currently pregnant?* This field is required.The HabitNu program is not recommended during pregnancy.
YESNO
17
Please tell us about your health insurance* This field is required.
Medicare
Medicaid
Medicare Advantage
Commercial Insurance
HOPE Trust
Self-pay
18
EligibleForProgram
YESNO
19
What is your Medicare number?* This field is required.Your Medicare Number is shown on the front of your Medicare card. This card is sometimes referred to as a Red, White and Blue Card. It is issued by the Social Security Office.
20
Do you have a secondary insurance card?* This field is required.
YESNO
21
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
22
What is your Plan name?* This field is required.
23
What is your Group #?
24
What is your Member ID #?* This field is required.
25
What is Your HOPE Trust ID Number? (Begins with ZZ)* This field is required.
26
Program
27
Race
28
Score
29
ReadinessScore
30
Weight Class
31
Diabetic patient email
example@example.com
32
EthnicityMapValue
33
RaceMapValue
34
Education
35
Referral Source
36
Enrollment Source
37
Eligible for CDC
YESNO
38
Tech Challenge Score
39
BMI
40
Bloodwork is OK
YESNO
41
A1c is OK
YESNO
42
Glucose is OK
YESNO
43
Asian BMI is OK
YESNO
44
User Wants Aid
YESNO
45
BMI is OK
YESNO
46
Todays date
Date
Year
Month
Day
47
days since 18th bday
48
Kickout Card
49
Insurance
50

Thank you for completing the risk test!

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

If you are part of the HOPE TRUST please email Sarah@clientsadvocate.com or Leah@clientsadvocate.com to discuss other program options.

All other interested individuals, please email info@myhealthrx.org.
51

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.
52
Would you like to register for the HabitNu program?* This field is required.
YES, I'd love toNO, not today
53
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.
54
Name* This field is required.
First Name
Last Name
55
Email* This field is required.This program requires that you have an active email address to participate
example@example.com
56
Mobile* This field is required.
57
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
58
Timezone* This field is required.
Eastern
Central
Mountain
Pacific
59
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.)
60
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
61
Highest grade or year of school completed?* This field is required.
Less than grade 12
High School Graduate
Some College or Technical School
College Graduate
62
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
63
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
64
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
65
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
66
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
67
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
68
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
69
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
70
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
71
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
72
How reliable is your Internet connection? Internet access is important because this program is done online.
Always on, fast
Reliable
Slow, but usable
Unreliable
73
Do you have challenges with access to healthy food?
YESNO
74
Do you have challenges accessing transportation?
YESNO
75
Do you have challenges accessing childcare?
YESNO
76
Do you have a safe place to become more active?
YESNO
77
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
78
This program is available for a fee of $50 per month. You will be contacted by your coach regarding your monthly payments
79
Thank you!

If you are interested in learning about other benefits available to you and you are part of the HOPE TRUST please email Sarah@clientsadvocate.com or Leah@clientsadvocate.com to discuss other program options.

All other interested individuals, please email info@myhealthrx.org.
80
Thank you for registering!

You have begun your journey to better health.

Congratulations, 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.

Please expect to hear from a member of your HabitNu Lifestyle Coaching Team in the next 3 business days.
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