Mini Health Clinic 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.
Date
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 prediabetes
I don't know
8
Was prediabetes or diabetes 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
Please tell us your gender?* This field is required.
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.This program is not recommended during pregnancy.
YESNO
16

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.
17

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 us at 352-227-3000 or visit our website to review other programs that you may be eligible for, www.mini-healthclinic.com
18
Program
19
User Program ID
20
Race
21
Score
22
ReadinessScore
23
Weight Class
24
EthnicityMapValue
25
RaceMapValue
26
Education
27
Referral Source
28
Enrollment Source
29
Tech Challenge Score
30
BMI
31
Eligible based on CDC Risk Test
YESNO
32
Bloodwork is OK
YESNO
33
A1c is OK
YESNO
34
Glucose is OK
YESNO
35
Asian BMI is OK
YESNO
36
BMI is OK
YESNO
37
Todays date
Date
Year
Month
Day
38
days since 18th bday
39
Insurance
40
Age
41
Age Points
42
CDC Points
43
Would you like to register for the HabitNu program?* This field is required.
YES, I'd love toNO, not today
44
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.
45
Name* This field is required.
First Name
Last Name
46
Email* This field is required.
example@example.com
47
Mobile* This field is required.
48
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
49
Zip code
50
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 community based 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.)
51
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
52
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
53
Please tell us about your health insurance* This field is required.
Medicare
Medicaid
Medicare Advantage
Commercial Insurance
Unknown
No insurance at this time
54
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.
55
What is your Group #?
56
What is your Member ID #?* This field is required.
57
Do you have a secondary insurance card?* This field is required.
YESNO
58
What is your Insurance Plan name?* This field is required.
59
What is your Group #?
60
What is your Member ID #?* This field is required.
61
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
62
What is your living situation today?* This field is required.
I have a steady place to live
I have a place to live today, but I am worried about losing it in the future
I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)
63
Think about the place you live. Do you have problems with any of the following?* This field is required.CHOOSE ALL THAT APPLY
Pests such as bugs, ants, or mice
Mold
Lead paint or pipes
Lack of heat
Oven or stove not working
Smoke detectors missing or not working
Water leaks
None of the above
64
Within the past 12 months, have you worried that your food would run out before you got money to buy more.* This field is required.
Often true
Sometimes true
Never true
65
Within the past 12 months, the food you bought just didn't last and you didn't have money to get more. * This field is required.
Often true
Sometimes true
Never true
66
In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?* This field is required.
YESNO
67
In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?* This field is required.
Yes
No
Already shut off
68
How often does anyone, including family and friends, physically hurt you?* This field is required.
Never
Rarely
Sometimes
Fairly often
Frequently
69
How often does anyone, including family and friends, insult or talk down to you?* This field is required.
Never
Rarely
Sometimes
Fairly often
Frequently
70
How often does anyone, including family and friends, threaten you with harm?* This field is required.
Never
Rarely
Sometimes
Fairly often
Frequently
71
How often does anyone, including family and friends, scream or curse at you? * This field is required.
Never
Rarely
Sometimes
Fairly often
Frequently
72
Abuse Score
73
How hard is it for you to pay for the very basics like food, housing, medical care, and heating?* This field is required.
Very hard
Somewhat hard
Not hard at all
74
Do you want help finding or keeping work or a job?* This field is required.
Yes, help finding work
Yes, help keeping work
I do not need or want help
75
If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc., do you get the help you need?* This field is required.
I don’t need any help
I get all the help I need
I could use a little more help
I need a lot more help
76
How often do you feel lonely or isolated from those around you?* This field is required.
Never
Rarely
Sometimes
Often
Always
77
Do you speak a language other than English at home?* This field is required.
YESNO
78
Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent.* This field is required.
YESNO
79
In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)?* This field is required.
0
1
2
3
4
5
6
7
80
On average, how many minutes did you usually spend exercising at this level on one of those days?* This field is required.
0
10
20
30
40
50
60
90
120
150 or greater
81
The next questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances are prescribed by a doctor (like pain medications), but only count those if you have taken them for reasons or in doses other than prescribed. One question is about illicit or illegal drug use, but we only ask in order to identify community services that may be available to help you.
82
How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.* This field is required.
Never
Once or Twice
Monthly
Weekly
Daily or Almost Daily
83
How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)?* This field is required.
Never
Once or Twice
Monthly
Weekly
Daily or Almost Daily
84
How many times in the past year have you used prescription drugs for non-medical reasons?* This field is required.
Never
Once or Twice
Monthly
Weekly
Daily or Almost Daily
85
How many times in the past year have you used illegal drugs?* This field is required.
Never
Once or Twice
Monthly
Weekly
Daily or Almost Daily
86
Over the past 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling down, depressed, or hopeless?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Not at all
Row 0, Column 0
Several days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly every day
Row 0, Column 3
Not at all
Row 1, Column 0
Several days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly every day
Row 1, Column 3
1 of 2
87
Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time. Do you feel this kind of stress these days?* This field is required.
Not at all
A little bit
Somewhat
Quite a bit
Very much
88
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (5 years old or older)* This field is required.
YESNO
89
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping? (15 years old or older)* This field is required.
YESNO
90
Thank you for Participating!

If you have any questions, please contact us at 352-227-3000 or visit our website to review other programs that you may be eligible for, www.mini-healthclinic.com
91
Thank you for registering!

Mini Health Clinic is excited to be a part of your health journey. We look forward to working with you and helping you reach your goals.

You will be contacted via email with more information about your start date, class schedule, & program details.
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