Simple Steps for Improving the Quality of Healthcare for Patients with Chronic Idiopathic Constipation

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* First Name First Name is required

Middle Name

* Last Name Last Name is required

* Are you a: Individual OR Clinic ?

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Additional Details

* Degree Degree is required Other Degree is required

* Specialty Specialty is required Other Specialty is required

* Practicing Type Practicing Type is required Other Practicing Type is required

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Name of Practice

*Practice Setting Practice Setting is required Other Practice Setting is required

ABIM ID ? Enter valid ABIM ID

ABIM DOB (mm/dd) Enter valid ABIM DOB

Type/Size of Practice

* How many of the clinicians in your practice are routinely involved in the diagnosis and management of patients with CIC? ? No. of clinicians is required Enter valid no. of clinicians

* How many patients with suspected or diagnosed CIC are seen in your institution each month? ?
No. of patients is required Enter valid no. of patients

Board Certifications (Optional):

AFM ID Number

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How many hours each week (on average) to you spend caring for patients at this facility? - Valid patient caring hours Relation With Facility:

Private physician from the community

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Number of Years In Practice:

1-5

5-10

10-15

>16

Number of Patients Seen Weekly:

1-25

26-50

51-100

>100

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This activity is provided by The University of Chicago Pritzker School of Medicine and the Academy for Continued Healthcare Learning (ACHL).

This activity is supported by an educational grant from Takeda Pharmaceuticals U.S.A., Inc.