HII: PreventT2 Pre-Assessment and Registration (2025)

PreventT2 Registration

Starts April 9 via WebEx
Location/Work Group*
Work Type*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age

18 - 3031 - 4041 - 5051 - 6060+
Email*
example@example.com
Which HII Family Health Center location best describes your location?*
Yes, I would like to register for the PreventT2 session.*

April 9 - December 10, 2025
Pre-Assessment

Please take a few minutes of your time to answer the questions below. These initial demographic questions are needed for program admission. They will be asked at the both the beginning and the end of the program to help us better understand the behavior change that occurs during the program. Please rest assured that all information you provide is confidential and will not be shared with your employer.

The first question on the pre-assessment requires you to take a pre-test created by the Centers for Disease Control and the American Diabetes Association. Here is the link to the pretest. Complete it and then enter your result in the box below.
Enter your result from the CDC pretest.*
Score should be >5.
What is your ethnicity?*
What is your highest level of education completed?*
What is your gender?*
What is your state of residence?*

Street Address

Street Address Line 2

CityState

Zip Code
What is your height? (in inches)*
ex. 64"
What is your starting weight? (in pounds)*
ex. 178
How much time in the past seven days have you spent exercising? (in minutes)*
ex. 30 + 40 + 15 + 25 = 110
How confident are you that you can lose weight?

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
How important is your health to you right now?

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Which statement below best describes your current physical activity level?

I don't walk/exercise regularly and don't plan to startI don't walk/exercise regularly but I've been thinking about startingI'm doing moderate or vigorous activity for at least 30 minutes on some days but fewer than five days a weekI've doing moderate or vigorous activity for at least 30 minutes in a day on five or more days a week and have been doing it for the last 1 to 6 monthsI've doing moderate or vigorous activity for at least 30 minutes in a day on five or more days a week and have been doing it for seven months or more

Please state how much you agree or disagree with the following statements:

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I am confident I can exercise if there is bad weather, when I'm tired or I feel I don't have time.
There are a variety of exercise activities I enjoy.
I feel a good amount of energy most days.
I sleep well most nights.

On average, how many hours of sleep do you get each night?

5

6

7

8

9

5 is or less, 9 is or more
Which statement below best describes your current diet?

I don't eat a diet consisting of fruits or vegetables, whole grains and lean protein regularly now, and I don't plan to start in the futureI don't eat a diet consisting of fruits or vegetables, whole grains and lean protein regularly now but I've been thinking about startingMy diet has consisted of some fruits and vegetables, whole grains and lean protein for the last 0 to 6 months.I eat a diet of fruits and vegetables, whole grains and lean protein every day (3 or more servings) for the last 0 to 6 months.I eat a diet of fruits and vegetables, whole grains and lean protein every day (3 or more servings) for 7 months or longer

Please state how much you agree or disagree with the following statements:

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I am confident I can make my diet healthier.
I am confident I can make healthy meals in the kitchen.
Before I choose what to eat I consider if it is healthy

	Never	Occasionally	Sometimes	Frequently	Always
How often do you drink soft drinks or other carbonated beverages?
In the last 2 weeks, how often did you buy food from a restaurant?
In the last 2 weeks, how often did your eat "instant" or "packaged" foods?

What inspired you to enroll in the program?

A health care provider (PCP, dietitian, physical therapist, etc.)A blood test resultPrediabetes risk testPast participantOther
In the past year have you had:

A fasting blood sugar between 100-125 mg/dL?A hemoglobin A1c between 5.7-6.4%?A timed oral glucose test between 140-199 mg/dL?None of the above
Do you have a history of gestational diabetes? (Diabetes during pregnancy)

YesNoNot applicable
How did you hear about this program? Select all that apply.*

BeWell Bulletin monthly newsletterDepartment meetingsDigital monitorsEmailEventmy.Hii.com/HIIbenefits.comMy leadermyquadmed.com/bewellMobile app (Ingalls Connect, HII TechKnow, NNS to Go)Nutrition Bytes monthly newsletterPostal mailPosterQuadMed provider/coachWellness OnlineWord of mouth
BeWell for Life wellness services are available to all HII employees, regardless of medical coverage. Some services may be limited to the HII Family Health Center or online.
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PreventT2 Registration