HabitNu Medicare Diabetes Prevention Program

1
What brought you here today?* This field is required.
I want to lose weight
I want to lower my blood sugar
My doctor recommended this
I’m exploring my options
2
How would you describe your current activity level?* This field is required.
Very Active
Moderately Active
Somewhat Active
Not Active
3
How tall are you?* This field is required.
Feet
Inches
4
How much do you weigh?* This field is required.
5
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
6
What sex were you assigned at birth, on your original birth certificate?* This field is required.
MaleFemale
7
How do you describe your current gender?
Woman
Man
Nonbinary
Transgender woman
Transgender man
Other
8
Does anyone in your family have type 2 diabetes?* This field is required.Family history is one of several risk factors for type 2 diabetes
Yes
No
Not Sure
9
Has a doctor or nurse ever told you that you have high blood pressure?* This field is required. This is an important part of your overall health picture.
Yes
No
Not Sure
10
Have you been diagnosed with diabetes?* This field is required.
Type 1 Diabetes
Type 2 Diabetes
Pre-diabetes
Not diagnosed with diabetes or prediabetes
Not sure
11
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
12
Have you ever had gestational diabetes during pregnancy?* This field is required.This is defined as high blood sugar during pregnancy.
YESNO
13

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.
14

Based on your answers, you may not qualify for this Medicare program. However, you can join a program to lose weight.

Lifestyle Change Program (Self-Pay) - A structured program focused on nutrition, activity, and daily habits, with optional GLP-1 support.

If you have any questions, please contact us at support@habitnu.com.
15

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

If you have any questions, please contact us at support@habitnu.com.
16
Program
17
User Program ID
18
Selected Language
19
User program id value
1
2
20
Race
21
Score
22
Weight Class
23
EthnicityMapValue
24
RaceMapValue
25
Education
26
Referral Source
27
Enrollment Source
28
BMI
29
Eligible based on CDC Risk Test
YESNO
30
Bloodwork is OK
YESNO
31
A1c is OK
YESNO
32
Glucose is OK
YESNO
33
Asian BMI is OK
YESNO
34
BMI is OK
YESNO
35
Todays date
Date
Year
Month
Day
36
days since 18th bday
37
Insurance
38
Age
39
Age Points
40
CDC Points
41
Rejection Status
42
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.
43
Where should we send your results?* This field is required.We’ll send your eligibility and next steps. Your information stays private.
Type your email address above
44
Name* This field is required.
First Name
Last Name
45
Mobile* This field is required.
46
Would you like to register for the HabitNu program?* This field is required.Good news — this program is covered at 100% by Medicare for those who qualify. Not covered? You can still join for just $45/month.
YESNO, not at this time
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Please tell us about your health insuranceHabitNu is a covered benefit under Medicare, Medicare Advantage, and select commercial insurance plans. We'll help you determine if you qualify for coverage. If your plan isn't listed, you can still join for just $45/month.
Medicare
Medicare Advantage
Commercial Insurance
Currently Uninsured
Other
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Thank you for participating.

We'd love to be part of your health journey. Please feel free to reach out at support@habitnu.com
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Thank you for registering!

Our team will send you an email shortly with details and next steps!

TO COMPLETE THE REGISTRATION HIT THE SUBMIT BUTTON BELOW.
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