Title Mr Mrs Ms
First name: (required)
Last name: (required)
E-mail: (required)
Practice address:
Address 1:
Address 2:
City/Town:
Postcode:
Telephone:
Fax:
Country Please choose a country Asia Australia Austria Belgium Brazil Canada China Denmark Europe Finland France Germany Hong Kong India Ireland Italy Japan Korea Latin America Mexico Netherlands Norway Singapore South Africa Spain Sweden Switzerland Taiwan UK United States
Address at which you wish to be contacted (if different from above):
How long have you been working as a nurse in the cardiovascular/diabetes area ?
<5 years 6-10 years 11-15 years >15 years
How would you categorise your role?
If PCT lead (please specify):
Other (please specify):
In your practice are you specifically responsible for care or clinics in:
Hypertension
Dyslipidaemia
Smoking cessation
Weight loss/obesity
Secondary prevention of CVD
Anticoagulation
Heart failure
Diabetes
Primary prevention of CVD
Diabetic foot care
Phase II cardiac rehabilitation
Phase III cardiac rehabilitation
Erectile dysfunction
How often are you involved in selection/switching/uptitration of drugs for:
In which of the following areas would you like to participate in programmes, advisory boards or board meetings:
Measurement/monitoring
Treatment
Lipid management
Diagnosis/monitoring
Type 2 diabetes
Insulin/oral therapy
Type 1 diabetes
Oral anti-diabetic agents
Weight loss
Weight loss programmes
Dietary advice
Drug therapy
Diagnosis
Cessation advice
Are you interested in programmes discussing new developments in:
Do you organise/facilitate patient education programmes in:
How often do you access the internet for:
Which website do you most frequently visit to gain information on:
