Empowering Older Adults Through Age-Friendly ENT: Provider 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 Provider 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 are you employed by?
*
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Matters Most
What questions do you have about incorporating what "matters most" into ENT care?
What challenges do you anticipate when addressing what "matters most" with your patients?
What additional tools or resources would make this easier to use in practice?
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Mentation
What questions do you have about incorporating "mentation" into ENT care?
What challenges do you anticipate when addressing "mentation" with your patients?
What additional tools or resources would make this easier to use in practice?
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Medication
What questions do you have about incorporating "medications" into ENT care?
What challenges do you anticipate when addressing "medications" with your patients?
What additional tools or resources would make this easier to use in practice?
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Mobility
What questions do you have about incorporating "mobility" into ENT care?
What challenges do you anticipate when addressing "mobility" with your patients?
What additional tools or resources would make this easier to use in practice?
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Have you reviewed the Provider Champion Program document?
*
Yes
No
Do you have any additional questions or suggestions?
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