Insert baseline questions: Program attended, number of patients seen in a week, years of practice
Pre-program (circle your answer)
Poor	Fair	Adequate	Good	Excellent
Post-program (circle your answer)
Poor	Fair	Adequate	Good	Excellent
Prior to attending this program, I did the following for respiratory device education:
□ I assumed patients were being trained by Allied Health Care Providers (ex. Pharmacist, RN, Nurse Practitioners, Certified Educators) and so I rarely educated on proper device technique
□ I did the majority of the respiratory device education for my patients
□ Other _____________________________________________
After attending this program, I have instituted device education in the following manner:
□ I now do the majority of the respiratory device education for my patients
□ Although I do not do the majority of device education, I have trained my support staff and AHCP’s to ensure it is done properly and on a consistent basis for most of my patients
□ I see the need for device education, however, I simply don’t have enough, and so far, for most patients, I still assume Allied Health Care Providers in my community (ex. Pharmacist, RN, Nurse Practitioners, Certified Educators) will educate my patients on proper device technique
□ Other _____________________________________________
When I ask the patient, “Show me how you use your device”, it usually takes ____ minutes to review their technique and make effective adjustments:
□ 1 minute	□ 2 minutes	□ 3–5 minutes	□ 10 minutes
□ Other (enter the exact number of minutes it takes you in the comment box)
Which view point best describes yours:
□ Device education should be given regardless of why a patient is seeing me – upon every visit
□ Device education should only be given to new and existing respiratory disease patients on device technique who are seeing me for their respiratory condition
□ Device education should only be given to patients with new prescriptions
Please list ideas/actions you have taken to ensure this education does not take up too much consult time ______________________________
List how you have changed your practice with respect to device education not mentioned above _____________________________________
Is there anything that you felt could have been added to the program? _ ______________________________________________________
List the most eye opening gem(s) you took away from this program: ______________________________________________________