Committment to Change/Evaluation and Credit Claim Form

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Please answer the following questions related to this educational activity.

(*) indicates required fields.


*After completing this activity I am able to:

Strongly agree (5) to Strongly Disagree (1)

1. Utilize references about healthy lifestyles and behavior
changes that impact patients' lives

 5

 4

 3

 2

 1

2. Implement strategies to assess patients’ readiness to change
poor lifestyle behaviors

 5

 4

 3

 2

 1

3. Counsel patients on lifestyle changes and provide action plans
when appropriate

 5

 4

 3

 2

 1

*This activity effectively targeted my needs.

 5

 4

 3

 2

 1

*I would recommend this activity to a colleague.

 5

 4

 3

 2

 1

*Please list at least two strategies that you will implement as a result of this activity:
Strategy 1*

Strategy 2*

Other strategies

*Did you perceive any commercial bias in this activity?
 Yes
 No

If yes, please specify

*How could this activity be improved?

Only physician participants (MD, DO, or equivalent international medical degree) are eligible to receive AMA PRA Category 1 Credit™. Physicians will receive a certificate of CME credit, indicating one (1) AMA PRA Category 1 Credit™ for each hour engaged in the learning activity, rounded to the nearest quarter credit (or hour). Physicians may claim credit in 15 minute, or 0.25 increments. Physicians must complete this form to receive AMA PRA Category 1 Credit™.

*First name

Middle initial

*Last name

*Degrees

ME number1 How do I find my ME number?

*Date of birth2 (mm/dd/yy)

*E-mail address (required for certificate)

*Total credits claimed (not to exceed 1.00)


1 The medical education [ME] number is an 11-digit number assigned to every physician in the US by the AMA for identification and recording of basic information. The ME number is found on the AMA membership card.

2 Date of birth assists in uniquely identifying physicians for purposes of credit processing.