NHMA

Program Enrollment

Step 1: Account Set up

Consumer Information

Check the box if you don't have an email.

Check the box if you don't have phone number

Cell Phone

Password can only contain alphanumeric and underscores.

Step 2: Consumer Registration

Mandatory Field:

First Name

Last Name

Consumer ID

Date of Birth

Gender

What is your race?

Are you Hispanic, Latino/a,or Spanish Origin?

Street Address

City

State

Zip Code

Home Phone

Organization Name

Community Health Worker ID

Step 3: Please complete this short survey:

Below are some statements that people sometimes make when they talk about their health. Please indicate how much you agree or disagree with each statement as it applies to you personally by circling your answer. Your answers should be what is true for you and not just what you think the doctor wants you to say.

	If the statement does not apply to you, circle N/A.	Disagree Strongly	Disagree	Agree	Agree Strongly	N/A
1	When all is said and done, I am the person who is responsible for taking care of my health
2	Taking an active role in my own health care is the most important thing that affects my health
3	I know what each of my prescribed medications do
4	I am confident that I can tell whether I need to go to the doctor or whether I can take care of a health problem myself.
5	I am confident that I can tell a doctor concerns I have even when he or she does not ask.
6	I am confident that I can follow through on medical treatments I may need to do at home
7	I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising
8	I know how to prevent problems with my health
9	I am confident I can figure out solutions when new problems arise with my health.
10	I am confident that I can maintain lifestyle changes, like eating right and exercising, even during times of stress.

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