Empowering Older Adults Through Age-Friendly ENT: Patient Champion Program
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Demographics
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your race and/or ethnicity? Check all that apply:
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Other
Prefer not to say
What is your gender?
*
Female
Male
Other
Prefer not to say
Please provide your email below to receive a certificate of participation in the Patient Champion Program.
example@example.com
Please provide your phone number below if you would prefer to be recontacted about future studies through phone calls. (Optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Which healthcare practice did you visit?
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Matters Most
Was anything in the what "matters most" section unclear or difficult to understand?
What questions do you still have about the what "matters most" section?
Is there any other information or resources about what "matters most" that would be helpful to you?
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Mentation
Was anything in the "mentation" section unclear or difficult to understand?
What questions do you still have about the "mentation" section?
Is there any other information or resources about "mentation" that would be helpful to you?
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Medication
What questions do you still have about the "medication" section?
Was anything in the "medication" section unclear or difficult to understand?
Is there any other information or resources about "medication" that would be helpful to you?
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Mobility
Was anything in the "mobility" section unclear or difficult to understand?
What questions do you still have about the "mobility" section?
Is there any other information or resources about "mobility" that would be helpful to you?
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Have you reviewed the Patient Champion Program document?
*
Yes
No
Do you have any additional questions or suggestions?
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