Counseling Points - Family/Pediatric Nurse 11/08 - (Page 15)

Counseling Points™: Program Evaluation Form Caring for Individuals with ADHD Throughout the Lifespan: An Introduction to ADHD Please mail or fax the completed form to NAPNAP, 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2634, Fax 856-857-1600. There is no fee for this educational activity but you must complete this form to receive acknowledgement for the activity. 1 = Strongly Disagree 2 = Disagree 3 = Somewhat Disagree Ì No 123456 123456 123456 123456 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 4 = Somewhat Agree 5 = Agree 6 = Strongly Agree Did you participate in the preassessment survey? Ì Yes To what extent do you agree with the following statements? (Please circle the appropriate number on the scale.) 1. ADHD is a highly inheritable psychiatric disorder. 2. Long-term nutritional intake of free sugars or artificial additives causes ADHD. 3. Tests such as an electroencephalogram (EEG), magnetic resonance imaging (MRI) scan, single photo emission computed tomography (SPECT) scan, or positron emission tomography (PET) scan are not usually needed to diagnose ADHD. 4. Psychiatric co-morbidities are common in patients with ADHD. To what extend were the following objectives satisfied? 5. State the prevalence and economic burden of attention deficit hyperactivity disorder (ADHD) 6. Discuss the pathophysiology and risk factors for ADHD 7. Determine the signs and symptoms of ADHD and common co-morbidities that may confound diagnosis 8. Identify ADHD across the lifespan To what extent was the content well-organized? 9. State the prevalence and economic burden of attention deficit hyperactivity disorder (ADHD) 10. Discuss the pathophysiology and risk factors for ADHD 11. Determine the signs and symptoms of ADHD and common co-morbidities that may confound diagnosis 12. Identify ADHD across the lifespan To what extent was the content easily understandable? 13. State the prevalence and economic burden of attention deficit hyperactivity disorder (ADHD) 14. Discuss the pathophysiology and risk factors for ADHD 15. Determine the signs and symptoms of ADHD and common co-morbidities that may confound diagnosis 16. Identify ADHD across the lifespan General Comments 17.The topic was current and relevant to my area of professional interest. 1 2 3 4 5 6 18.The program was free of commercial bias. 1 2 3 4 5 6 19.The program increased my awareness and understanding of the subject matter. 1 2 3 4 5 6 20.As a result of this continuing education activity (check only one): Ì I will modify my practice. Ì I will wait for more information before modifying my practice. Ì The program reinforces my current practice. Suggestions for future topics/additional comments: Follow-up As part of our continuous quality improvement effort, we conduct post-activity follow-up surveys to assess the impact of our educational interventions on professional practice. Please check one: Ì Yes, I would be interested in participating in a follow-up survey. Ì No, I would not be interested in participating in a follow-up survey. Patient Education Follow-up Would you be interested in receiving an educational magazine on ADHD to distribute to your patients? Posttest Answer Key A10-08-E31 Request for Credit Name Type of Degree Organization Specialty Address City State ZIP Phone Fax E-mail Signature Date 1 2 3 4 5 6 7 8 9 Ì Yes 10 Ì No Fax form to 856-857-1600 15 NOVEMBER 2008

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Counseling Points - Family/Pediatric Nurse 11/08

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