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Evaluation of this Program (Behavioral Health)
1.
Was the information presented in this activity biased and/or compromised by commercial support?
Yes
No
If Yes, please explain.
2.
How do you rate Dr. Twillman's delivery of this education?
Excellent
Very Good
Average
Needs Improvement
3.
Did this activity meet its stated learning objectives?
Check ALL that were met
.
Determine three major public health problems.
Define three contributors to pain.
Analyze how to restore and achieve balance in pain management.
Review the typical cycle that individuals with chronic pain experience and how to manage these cycles in practice.
4.
How do you rate Dr. Gokani's delivery of this education?
Excellent
Very Good
Average
Needs Improvement
5.
Did this activity meet its stated learning objectives?
Check ALL that were met
.
Determine the status of health and healthcare.
Illustrate the link between the gut, brain, and pain.
Analyze and define our three brains.
Review a new paradigm for brain health.
6.
Did this activity provide new information to you?
Yes
No
7.
Was the educational approach used in this activity conducive to your learning experience?
Yes
No
8.
Was the information presented applicable to your clinical practice?
Yes
No
9.
Will the information presented help you to improve your patients’ outcomes?
Yes
No
10.
This activity increased my knowledge, competence, and/or will improve my performance in my practice
Yes
No
11.
Of the patients you will see in the next week, about how many will benefit from the information you learned by participating in this activity?
1-10
11-25
26-50
>50
12.
Based upon your participation in this activity, do you intend to change your practice behavior?
Yes, I plan to implement changes in my practice based on the information presented
No, I need more information before I will make any changes to my practice behavior
Not applicable – My current practice has been reinforced by the information presented
13.
If you plan to change your practice behavior, what type of change(s) do you plan to implement? Check all that apply.
Differentiate and diagnose pain conditions.
Treat and manage pain conditions.
Utilize pain management techniques on a case-by-case basis
Recognize patients that qualify for therapy to expand management capabilities.
14.
Are there any barriers that would keep you from implementing the practice paradigms discussed in this activity?
Lack of evidence-based guidelines
Lack of applicability of guidelines to my current practice and/or patients
Lack of time
Organizational/Institutional
Insurance/Financial
Patient Adherence/Compliance
Treatment related adverse events
No perceived barriers
Other (please specify)
15.
Please give us your overall comments regarding this activity.
16.
Claim Credit
I certify that I have participated in the number of hours (0.25 increments, up to 6.25 hours chosen below) of this educational activity and request a CME certificate indicating that number of credits. I will claim only the total number of hours for which I participated. [Please print legibly.]
17.
Number hours you participated in this activity (0.25 increments, up to 6.25 hours).
1.0
0.75
0.5
0.25
18.
Please Fill out the form below for your CME/CE Certificate
First and Last Name
Title (MD, DO, NP, PA, RN, etc.)
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
19.
What is your specialty (Ex. Family Practice, Neurology, etc)
20.
How many years have you been in practice?
< 10
10-20
21-30
> 30
21.
How many days a week do you see patients?
0-1
2-3
4-5
6-7
22.
How many patients do you typically see per day?
0-10
11-20
21-30
31-40
> 40
23.
What is your practice like?
Solo or small group (1-5 providers)
Large group (> 5 providers)
Government Owned Facility/Clinic
Retired/Not Seeing Patients
Other (please specify)