Registration Form

Session 1:
Chagas Disease in the USA: Screening, Diagnosis, and Treatment for Primary Care Clinicians

Welcome!

Please register below to access the webinar.

Once you submit, you will be redirected to the webinar recording and evaluation to obtain CME/CNE credit.

**If you would like the recording link to be sent to you, kindly check "send me a copy of my responses" at the bottom of this form.**

First Name

Last Name

Email Address

City

Country/Region

Zip Code/Postal Code

State/Province

Phone Number

Organization

Occupation

If you put "Other", please write your occupation:

Credentials

If you put "Other", please write your credentials:

What is your primary specialization?

If you put "Other", please write specialization

What is your primary type of medical practice?

(non-physicians put "Does not apply")

If you put "Other",

please write your primary type of medical practice:

How many years have you been in the medical field?

How would you describe your level of knowledge

of Chagas Disease?

How confident are you that your knowledge

on Chagas Disease is up to date?

How confident are you in your ability to screen,

diagnose, or treat a patient with Chagas disease?

Have you ever screened, diagnosed, or treated a

patient with Chagas disease?

How willing are you to actively screen

your patient population or community for Chagas disease?

The following are questions about your knowledge of Chagas disease:

Chagas disease is caused by a _______?

In what parts of the world is Chagas disease

transmitted by vector bugs? (choose the best answer)

Acute and chronic Chagas disease are

characterized by which of the following?

People with chronic Chagas disease may have:

Is there a recommended treatment available in

the U.S. to those with Acute or Chronic asymptomatic Chagas disease?

Are you interested in earning CME or CNE credits?

Send me a copy of my responses

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Registration FormSession 1:Chagas Disease in the USA: Screening, Diagnosis, and Treatment for Primary Care Clinicians

The following are questions about your knowledge of Chagas disease:

Registration Form

Session 1:
Chagas Disease in the USA: Screening, Diagnosis, and Treatment for Primary Care Clinicians