CME Evaluation Survey Please complete and return this form on the date of completion in order to receive CME credit. CME Evaluation Survey Title of Lecture* CME Course Number* Name* First Last Email* Date* MM slash DD slash YYYY Will information gained from this program result in enhancing optimal patient care?*YesNoIf yes, please list change(s) you intend to make in your practice as a result of this program. Please rate your confidence in implementing these changes.*High ConfidenceModerate ConfidenceLow/No ConfidenceN/APlease identify any barriers you perceive in implementing these changes (select all that apply).*CostPatient compliance issuesLack of administrative support/resourcesInsurance/reimbursement issuesLack of consensus of professional guidelinesLack of time to assess/counsel patientsHow will you address these barriers to implement changes in knowledge and behavior? The material was presented at an appropriate level.*PoorFairAverageGoodExcellentI have gained knowledge that will improve patient care.*PoorFairAverageGoodExcellentThe program content was objective, balanced and free from commercial bias or influence.*PoorFairAverageGoodExcellentDid the program meet your expectations in accomplishing the stated educational objectives?*PoorFairAverageGoodExcellentPlease provide your overall rating of the quality of the education offered watching this program.*PoorFairAverageGoodExcellentAdditional Comments/SuggestionsHow can this program be improved? (Please list both strengths and weaknesses.) Based on your educational needs, please provide us with suggestions for future program topics and formats:
