Enroll

1Start

2Your Wellness

3Your Schedule

4Lifemap Setup

Let's Get Started
Please completed this short survey for blood sugar tracking. We will use it to send you text reminders to check your blood sugar. You will be able to submit your readings on a mobile web form. This way you will not need to worry about writing them down or bringing a journal for your visits. You’ll be able to view charts and graphs so that you can see your progress and have better control.

Please complete the form to set up your LIFEMAP.
* = required field
Name*
First Last
Date of Birth
Must be at least 18 years of age.
MM slash DD slash YYYY
Mobile Number*
You will receive reminders to check your blood sugar on the schedule defined in this form. In addition, you will receive 3-4 diabetes education and support care messages/week. LIFEMAP text care messages will come from phone number 53016. Message and data rates may apply according to your carrier text and data plan. You can opt out at any time by replying STOP to any message or you can get help with the LIFEMAP program by replying HELP.
Zip Code*
Gender at birth*
- Female
- Male
Education*
- Did not complete high school
- High school
- Some college
- Completed college
- Advanced degree
What type of mobile phone do you have?*
- Smartphone (e.g. iPhone, Android, Windows phone)
- Regular phone no data plan

Your Schedule
Your current schedule. Please put one approximate time for each item.
Wakeup Time*

: Hours

Minutes

AM/PM
Breakfast Time of First Food*

: Hours

Minutes

AM/PM
Snack Time (optional)

: Hours

Minutes

AM/PM
Lunch Time (optional)

: Hours

Minutes

AM/PM
Snack Time (optional)

: Hours

Minutes

AM/PM
Dinner Time*

: Hours

Minutes

AM/PM
Snack Time (optional)

: Hours

Minutes

AM/PM
Bedtime*

: Hours

Minutes

AM/PM
Sleep patterns*
- Frequent insomnia
- Disrupted sleep
- Great sleeper

	Strongly agree	Agree	Not sure	Disagree	Strongly disagree
When all is said and done, I am the person who is responsible for managing my health condition.
Taking an active role in my own health care is the most important factor in determining my health and ability to function.
I am confident that I can take actions that will help prevent or minimize some symptoms or problems associated with my health condition.
I am confident that I can tell when I need to go get medical care and when I can handle a health problem myself.

Let's Get Started