Diabetes Registration – Attane Health

We know managing our health through diet and nutrition can often be confusing, time-consuming, and expensive. That's why we built Attane Health - a place you can easily shop, learn, and connect with others - all in one place.

First Name*

Last Name*

Shipping Address*

Street Address City State ZIP Code

Enter your 10-digit Invite Code:*

You can find your invite code in your welcome email.
Include hyphens when entering the code.

Hidden

State

Your Login

Create a strong password. If you don't have an email address you'll be able to login with your mobile phone.

Email*

Mobile Phone

Password*

Enter Password Verify Password

Strength indicator

Minimum of 10 characters long and contain at least one uppercase and one lowercase letter (A,z), one numeric character (0-9), and one special character (such as !, %, @, or #)

Date of Birth*

Gender*

What is your race?*

Select all that apply

American Indian or Alaska Native

Asian Indian

Black

Chinese

Filipino

Guamanian or Chamorro

Hispanic

Japanese

Korean

Native Hawaiian

Other Asian

Samoan

Other Pacific Islander

Vietnamese

White

Other

Other Race*

Do you have any food allergies or intolerances?*

Select all that apply

Egg

Fish

Milk / Dairy

Peanut

Sesame

Shellfish (e.g., shrimp, crab, lobster)

Soy

Tree Nut (e.g., almonds, cashew, hazelnut)

Wheat

Other

No food allergies or intolerances

Other Allergy or Intolerance*

Do you have any existing health conditions?*

Select all that apply

None

Hypertension (high blood pressure)

Eczema

Cancer

Crohn’s Disease

Celiac Disease

Diabetes - Type 1

Diabetes - Type 2

Gastrointestinal Disease

Heart Disease

Kidney Disease

Sickle Cell Disease

Asthma

Thyroid Disorders

Other

Other Health Condition

Have you seen your doctor or diabetes specialist in the last 12 months for your diabetes?*

Yes

Do you check your glucose levels (blood sugar) at least once a day?*

Yes

Sometimes

N/A

Are you able to afford food that makes it easy for you to achieve good glucose (blood sugar) levels?*

Yes

Sometimes

N/A

Are you physically active (exercise, walking, etc) 3 times a week or more to improve your diabetes and health?*

Yes

Sometimes

N/A

Do any of the following dietary preferences or restrictions apply to you based on your religion or cultural background?*

Check all that apply

Vegetarian

Vegan

Halal

Kosher

Gluten-free

Lactose intolerant

Other

N/A

Other dietary preferences or restrictions

How would you describe your current nutrition knowledge?*

Very low

Low

Moderate

High

Very High

Tell us about your household

The following questions ask about your household. For these questions, your household includes you and anyone else who lives with you in your place of residence (e.g. home, apartment). This includes your spouse, any other family members, or roommates.

How many Adults currently live in your household?*

Adults 18+ years

How many Children currently live in your household?*

Children 0-17 years

Which language(s) do you speak?*

Select all that apply

English

Spanish

Chinese (e.g., Mandarin, Cantonese)

Tagalog

Vietnamese

French

Arabic

Korean

Russian

Other

Other Language

Over the past 12 months, how many times did you utilize an emergency food provider (e.g., a food pantry)?*

Never

1-5 times

6-10 times

11 or more times

Within the past 12 months we worried whether our food would run out before we got money to buy more.*

Often True

Sometimes True

Never True

Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.*

Often True

Sometimes True

Never True

How do you prefer to receive updates and information from us?*

SMS/Text Messages

Phone Calls

Social Media

Website/App Notifications

Postal Mail

Consent*

I agree to receive SMS text notifications

By submitting this form, you agree to receive SMS updates on your order status and reminders from Attane Health. Msg&data rates may apply. You can opt-out at any time by replying "STOP". For assistance, reply "HELP". Your information will be handled in accordance with our Privacy Policy.

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Tell us about your household