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Please answer the following questions so that we may quickly develop your order: (*)Indicates a mandatory question.  * A) Your Position at the Practice -----Select----- Doctor Physician Assistant Nurse Practitioner Nurse Office manager Receptionist Other clerical or administrative staff  * B) Practice Setting -----Select----- Convenient Care Clinic Urgent Care Hospital General outpatient clinic Community Clinic Free Clinic Specialist Clinic VA Hospital/Clinic Federally Qualified Health Center Other  * C) Practice Type (Check all that apply) Primary care Family medicine Internal medicine Geriatric medicine Gastroenterology Urology Obstetrics/Gynecology Endocrinology Cardiology Oncology Other Specialized practice (please specify)  * D) What is the number of full time physicians in the practice? -----Select----- More than 10 (Kit #1) 6-10 (Kit #2) 0-5 (Kit #3)  * E) Would you like some portion of your kit to include Spanish language literature? (Note: Spanish language literature is not available for VA Hospital/Clinic Kits) -----Select----- No Yes, 25% Spanish language literature Yes, 50% Spanish language literature Yes, 75% Spanish language literature  * F) Where did you learn about this product? -----Select----- Newsletter (electronic or print) Professional Conference/Meeting Email Journal On-site Visit Website CoC QIO Unknown    G) From which source did you learn about this product? -----Select----- Employer American Cancer Society American Diabetes Association American Heart Association Professional Medical Society Other    H) Roughly what percentage of your patient population has the following insurance status? Privately Insured: % Medicare: % Medicaid: % None: %    I) Roughly what percentage of your patient population has the following ethnic background? Black or African American: % Hispanic or Latino: % Asian: % Hawaiian or Other Pacific Islander: % White: % American Indian or Alaska Native: % Other or not sure: %    J) Where do you plan on displaying the cards in your practice? (Check all that apply) In the waiting room area At the reception desk In the exam room Other    K) How do the healthcare professionals in your practice plan to use the card? (Check all that apply) Hand the card out directly to patients Let the patients take card at their leisure
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