Gold Coast

1
What is your date of birth? * This field is required. You need to be 18 or older to participate in HabitNu.
Date
Month
Day
Year
2
How would you describe your current activity level?
Very Active
Moderately Active
Somewhat Active
Not Active
3
How tall are you?* This field is required.
Feet
Inches
4
What is your current weight?* This field is required.
5
For medical purposes, what was your sex assigned at birth?* This field is required.Your genes can make a difference.
MaleFemale
6
Are you currently pregnant?* This field is required.This program is not recommended during pregnancy.
YESNO
7

Thank you for completing the risk test

The HabitNu Diabetes Prevention Program is not recommended for pregnant women. Based on this answer, you are not currently eligible for this program.

If you would like to learn more about your health, call Gold Coast Health Plan (GCHP) Health Education Department at 1-805-437-5961, Monday through Friday, 8 a.m. to 5 p.m. (except holidays). If you use a TTY, call 711.
8
Please select your race.* This field is required.Some race / ethnic minorities have a higher prevalence of diabetes, and this helps us provide you with the most relevant support.
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
Has a doctor or nurse ever told you that you have high blood pressure? This is an important part of your overall health picture.
Yes
No
Not Sure
10
Does anyone in your family have type 2 diabetes?Family history is one of several risk factors for type 2 diabetes
Yes
No
Not Sure
11
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 prediabetes
Not sure
12
Have you been diagnosed with prediabetes through a blood test?
YESNO
13
Do you know your most recent HbA1c? It’s OK if you don’t have this information right now. Just leave the field blank and click next to continue.
14
Do you know your most recent fasting blood glucose level?It’s OK if you don’t have this information right now. Just leave the field blank and click next to continue.
15
Have you ever had gestational diabetes during pregnancy? * This field is required.This is defined as high blood sugar during pregnancy.
YESNO
16

HabitNu is a great fit for you!

Based on your responses, our CDC-recognized HabitNu Diabetes Prevention Program is one of the most effective ways to lose weight and prevent the onset of type 2 diabetes.

Next, answer a few more questions to help us learn more about you, and to see how HabitNu will support you on your journey to better health!
17

Thank you for completing the risk test

Based on your answers, you are not currently eligible for this Diabetes Prevention Program.

If you would like to learn more about your health, call [Gold Coast Health Plan (GCHP)] Health Education Department at 1-805-437-5961, Monday through Friday, 8 a.m. to 5 p.m. (except holidays). If you use a TTY, call 711.
18
Program
19
User Program ID
20
Selected Language
21
User program id value
1
2
22
Race
23
Score
24
Weight Class
25
EthnicityMapValue
26
RaceMapValue
27
Education
28
Referral Source
29
Enrollment Source
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
Rejection Status
44
HIPAA Patient Consent* This field is required.To begin your HabitNu Diabetes Prevention Program, please consent to allow us to protect your health information and provide you with personalized support.
45
Please share your name with us. * This field is required.This is the name we will use to confirm that this program is covered by your insurance provider.
First Name
Last Name
46
What’s the best email address to reach you at?* This field is required.This will also be used as your username to access your HabitNu account.
example@example.com
47
What’s your phone number? * This field is required.Your coach may use this number to reach you during your program.
48
What’s your address?* This field is required.We will use this to verify your insurance eligibility, and send program support tools if they are included.
Street Address
Street Address Line 2
City
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* This field is required.
50
Timezone
Eastern
Central
Mountain
Pacific
51
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.)
52
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
53
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
54
Great News!

HabitNu's Diabetes Prevention Program is a covered benefit through Gold Coast Health Plan.

Let's gather your insurance information so we can handle the billing for you.
55
What is your insurance or Medi-Cal plan name?* This field is required.
Medi-Cal (Gold Coast Health Plan)
I am unsure
56
What is your Medi-Cal Plan Name?* This field is required.
57
What is your Medi-Cal Member ID number?* This field is required.This number should begin with a 9 and end with a letter.
58
What is your insurance plan name?* This field is required.
59
What is your member ID?* This field is required.
60

Last step!

To begin your HabitNu program, click the SUBMIT button to complete registration!

You will receive an email from HabitNu that will have more information about your program start date and next steps.
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