HabitNu MDPP Enrollment Survey

1

Please share your name with us. We'll use this name to confirm that this program is covered by your insurance provider.

First Name

Last Name

2

What’s the best email address to reach you at?This will also be used as your username to access your HabitNu account.

example@example.com

3

What’s your phone number? Your coach may use this number to reach you during your program.

Area Code

Phone Number

4

HIPAA Patient ConsentTo begin your HabitNu Diabetes Prevention Program, please consent to allow us to protect your health information and provide you with personalized support.

I have reviewed the HabitNu consent form and agree to participate in the program

5

What is your date of birth?* This field is required. You need to be 18 or older to participate in HabitNu.

Date

6

How would you describe your current activity level?

Very Active

Moderately Active

Somewhat Active

Not Active

7

How tall are you?* This field is required.

Feet

Inches

8

What is your current weight?* This field is required.

9

For medical purposes, what was your sex assigned at birth?* This field is required.Your genes can make a difference.

MaleFemale

10

Are you currently pregnant?* This field is required.This program is not recommended during pregnancy.

YESNO

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

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

13

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

14

Have you been diagnosed with diabetes?* This field is required.Diabetes can be hereditary!

Type 1 Diabetes

Type 2 Diabetes

Pre diabetes

Not diagnosed

Not sure

Other

15

Have you ever had gestational diabetes during pregnancy? * This field is required.This is defined as high blood sugar during pregnancy.

YESNO

16

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.

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Program

18

User Program ID

19

Selected Language

20

User program id value

1

2

21

Race

22

Score

23

Weight Class

24

EthnicityMapValue

25

RaceMapValue

26

Education

27

Referral Source

28

Enrollment Source

29

BMI

30

Eligible based on CDC Risk Test

YESNO

31

Bloodwork is OK

YESNO

32

A1c is OK

YESNO

33

Glucose is OK

YESNO

34

Asian BMI is OK

YESNO

35

BMI is OK

YESNO

36

Todays date

Date

37

days since 18th bday

38

Insurance

39

Age

40

Age Points

41

CDC Points

42

Rejection Status

43

Zip Code* This field is required.

44

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.)

45

What is your insurance or Medi-Cal plan name?* This field is required.

Medicare

Medicare Advantage

Unsure

46

Last step!

Click SUBMIT to complete your HabitNu enrollment survey.

After you submit, check your inbox for a welcome email with instructions to set up your HabitNu account and continue enrollment.

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