Fill out Form to Reserve Your Spot at the Free Sleep Medicine Dinner Seminar

First Name *

Last Name *

Email (we will keep it completely private) *

Phone *

Address *

City, State, Zip *

Profession *

Specialty *

We are tracking the impact this educational activity has on your practice. Please answer the following survey questions. We will send you an identical questionnaire via the web in the next 90 days to assess change. Thank you.

1. In the past month how many patients have you diagnosed with a sleep disorder? *

A. Less than 5
B. 6-15
C. 16-20
D. 21-50
E. 51 or more

2. In the past month how many patients have you sent for a sleep medicine consultation or sleep testing? *

A. Less than 5
B. 6-15
C. 16-20
D. 21-50
E. 51 or more

3. In the past month how many patients have you prescribed a drug for treatment of a sleep disorder (e.g. hypnotic, dopamine agonist, wake promoting etc…)? *

A. Less than 5
B. 6-15
C. 16-20
D. 21-50
E. 51 or more

4. In the past month how many patients have you prescribed some form of positive pressure therapy for sleep apnea (e.g. CPAP, BiLevel)? *

A. Less than 5
B. 6-15
C. 16-20
D. 21-50
E. 51 or more

5. How often do you ask your patients about their sleep? *

1 Never
2 Rarely
3 Occasionally
4 Most of the time
5 Always

6. Sleep quality is important to my patient's health. *

1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly Agree

7. How did you hear about this dinner seminar? *

Comments? Questions?

Subject

1100 Johnson Ferry Road, Suite 580, Atlanta, GA 30342
Phone: 678-651-2000 Fax: 678-651-2025