PulseConnect Registration
Name
*
First Name
Last Name
Email
*
example@example.com
Company
*
Professional Title
*
Address Type
*
Please Select
Business
Residential
Address
*
Please indicate your license titles:
*
CDCES
CMA
CNM
DO
DTR
LDN
LPN
MD
MPH
ND
MS
NP
PA
PhD
PharmD
RD/RDN/LDN/CDN
RN
RPh
Other
Which best describes your primary specialty?
*
Please Select
Cardiology
Dermatology
Diabetes
Endocrinology
Fitness or Exercise
Family Practice
Functional Medicine
Gastroenterology
General Practice
Geriatric Medicine
Integrative Medicine
Internal Medicine
Lifestyle Medicine
Naturopathic Medicine
Nutrition
Obstetrics/Gynecology
Oncology
Pediatrics
Pharmacy
Physical Medicine/Rehabilitation
Primary Care
Reproductive Medicine
Sports Medicine
Urology
Women's Health
Which best describes your secondary specialty?
*
Please Select
Cardiology
Dermatology
Diabetes
Endocrinology
Fitness or Exercise
Family Practice
Functional Medicine
Gastroenterology
General Practice
Geriatric Medicine
Integrative Medicine
Internal Medicine
Lifestyle Medicine
Naturopathic Medicine
Nutrition
Obstetrics/Gynecology
Oncology
Pediatrics
Pharmacy
Physical Medicine/Rehabilitation
Primary Care
Reproductive Medicine
Sports Medicine
Urology
Women's Health
Which best describes your primary work setting?
*
Please Select
Community Health Center or Clinic
Corporate Workplace
Early Childcare Education
Government Agency
Gym/Fitness Center
Home Health
Hospital or Institution, Inpatient
Hospital or Institution, Outpatient
K-12 School or School District
Long Term Care or Assisted Living Facility
Managed Care Organization
Private Practice, Solo
Private Practice, Group
Public Health
Retail, Grocery, or Drug Store
College/University
Telehealth
Other
If other, please specify:
How many people do you counsel, coach or advise per week?
*
Please Select
None. I do not counsel, coach, or advise people
1-10 people per week
11-50 people per week
More than 50 people per week
On which of the following topics do you regularly counsel patients or clients?
*
Allergies
Diabetes
Digestive Health
Fitness and Exercise
Heart Health
Immune Health
Nutrition
Nutritional Supplements
Pediatrics
Senior Health
Weight Management/Obesity
Women's Health
None of the above
Which of the following do you use for your professional work and/or to share health and wellness information?
*
Facebook
Instagram
X/Twitter
TikTok
Blog
Local TV
Local Newspaper
LinkedIn
None of the above
What percentage of your patients or clients are Spanish-only speakers/readers?
*
Intervals of 5%
What percentage of your patients or clients qualify for/are on WIC?
Intervals of 5%
How do you see patients?
*
In person
Virtually
Both in person & virtually
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