Please define your role in enteral nutrition
Caregiver
Consumer
Dietitian or nutritionist
Nurse
Nurse practitioner or physician assistant
Physician
Surgeon
Pharmacist
Other
Caregiver
Consumer
Dietitian or nutritionist
Nurse
Nurse practitioner or physician assistant
Physician
Surgeon
Pharmacist
Other
Please indicate the age of consumer (in years)
Please indicate your age (in years)
In which CONTINENT do you live?
Northern America (includes Canada, USA, Central America and Carribean)
South America
Europe
Asia
Northern America (includes Canada, USA, Central America and Carribean)
South America
Europe
Asia
In which state/country do you live?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon Belize Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Other
Please use the "Other" option if your practice country/state is not in the list. Thank you.
Please describe "Other" state/country:
In which country do you live (South America)?
Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela
In which country do you live (Europe)
Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Italy Kazakhstan Kosovo Latvia Liechtenstein Lithuania Luxembourg Malta Moldova Monaco Montenegro Netherlands North Macedonia (formerly Macedonia) Norway Poland Portugal Romania Russia San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Turkey Ukraine United Kingdom (UK) Vatican City (Holy See)
In which country do you live (Asia)
Afghanistan Armenia Azerbaijan Bahrain Bangladesh Bhutan Brunei Burma Cambodia China Cyprus Georgia Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan North Korea South Korea Kuwait Kyrgyzstan Laos Lebanon Macau Malaysia Maldives Mongolia Nepal Oman Pakistan Palestine Philippines Qatar Saudi Arabia Singapore Sri Lanka Syria Taiwan Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen
In which City do you live?
What is the consumer's primary diagnosis?
Stroke or Neurological
Motility disorder
Cancer
Developmental delay from an underlying illness
Other
Stroke or Neurological
Motility disorder
Cancer
Developmental delay from an underlying illness
Other
What is your primary diagnosis?
Stroke or Neurological
Motility disorder
Cancer
Developmental delay from an underlying illness
Other
Stroke or Neurological
Motility disorder
Cancer
Developmental delay from an underlying illness
Other
Please describe 'Other' primary diagnosis
Please describe 'Other' primary diagnosis
Since when have you been providing tube feeds for the consumer?
Today M-D-Y
Since when have you been on tube feeds?
Today M-D-Y
What type of connector is your home care company/DME (Durable Medical Equipment) provider supplying you?
ENfit type
Legacy type
Both (using a combination of ENfit and Legacy products)
Don't know/not sure
ENfit type
Legacy type
Both (using a combination of ENfit and Legacy products)
Don't know/not sure
Example images of ENfit and Legacy type connectors:
Since when has the consumer had their current connector?
Today M-D-Y
Since when have you had your current connector?
Today M-D-Y
Do you know what type of connector your local hospital is using?
ENfit type
Legacy type
Both
Don't know/not sure
ENfit type
Legacy type
Both
Don't know/not sure
Have you heard about ENfit connectors?
Yes
No
Do you have any concerns about transitioning to ENFit?
Is your retail pharmacy providing ENfit syringes for medication administration?
No Yes I Don't Know
What type of feeding tube does the consumer currently have?
Standard Gastric tube
Standard Jejunal tube
Gastro-jejunal tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastric tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) jejunal tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastro-jejunal tube
Naso-gastric tube
Naso-jejunal tube
Don't know/not sure
Standard Gastric tube
Standard Jejunal tube
Gastro-jejunal tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastric tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) jejunal tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastro-jejunal tube
Naso-gastric tube
Naso-jejunal tube
Don't know/not sure
What type of feeding tube do you currently have?
Standard Gastric tube
Standard Jejunal tube
Gastro-jejunal tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastric tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) jejunal tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastro-jejunal tube
Naso-gastric tube
Naso-jejunal tube
Don't know/not sure
Standard Gastric tube
Standard Jejunal tube
Gastro-jejunal tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastric tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) jejunal tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastro-jejunal tube
Naso-gastric tube
Naso-jejunal tube
Don't know/not sure
What size of tube does the consumer use?
8 Fr
10 Fr
12 Fr
14 Fr
16 Fr
18 Fr
20 Fr
22 Fr
24 Fr
26 Fr
Don't know/not sure
8 Fr
10 Fr
12 Fr
14 Fr
16 Fr
18 Fr
20 Fr
22 Fr
24 Fr
26 Fr
Don't know/not sure
Fr = size in French (units)
What size of tube do you use?
8 Fr
10 Fr
12 Fr
14 Fr
16 Fr
18 Fr
20 Fr
22 Fr
24 Fr
26 Fr
Don't know/not sure
8 Fr
10 Fr
12 Fr
14 Fr
16 Fr
18 Fr
20 Fr
22 Fr
24 Fr
26 Fr
Don't know/not sure
Fr = size in French (units)
What is the location of the consumer's feeding tube tip?
Stomach
Intestines
Both
Don't know
Stomach
Intestines
Both
Don't know
What is the location of your feeding tube tip?
Stomach
Intestines
Both
Don't know
Stomach
Intestines
Both
Don't know
What type of enteral feeding does the consumer use? (Check all that apply)
Commercial formula (example: Ensure, Boost, Jevity, Pediasure, Peptamen)
Commercial blenderized tube feeding (example: Compleat Organic Blends, Liquid Hope, Nourish, Pediasure Harvest, Real Food Blends)
Homemade blenderized tube feeding
Other
Commercial formula (example: Ensure, Boost, Jevity, Pediasure, Peptamen)
Commercial blenderized tube feeding (example: Compleat Organic Blends, Liquid Hope, Nourish, Pediasure Harvest, Real Food Blends)
Homemade blenderized tube feeding
Other
Select all that apply
What type of enteral feeding do you use?(Check all that apply)
Commercial formula (example: Ensure, Boost, Jevity, Pediasure, Peptamen)
Commercial blenderized tube feeding (example: Compleat Organic Blends, Liquid Hope, Nourish, Pediasure Harvest, Real Food Blends)
Homemade blenderized tube feeding
Other
Commercial formula (example: Ensure, Boost, Jevity, Pediasure, Peptamen)
Commercial blenderized tube feeding (example: Compleat Organic Blends, Liquid Hope, Nourish, Pediasure Harvest, Real Food Blends)
Homemade blenderized tube feeding
Other
Select all that apply
Please describe 'Other' enteral formula
Do you add Multivitamin in addition to enteral feeds?
Yes No
How do you provide the consumer's tube feeds?(Check all that apply)
Select all that apply
How do you provide your tube feeds?(Check all that apply)
Select all that apply
Enteral feeds provide what percentage of the consumer's daily calorie needs?
0 - 24.9%
25 - 49.9%
50 - 74.9%
75 - 99.9%
100% (Enteral feeds are the sole source of nutrition)
0 - 24.9%
25 - 49.9%
50 - 74.9%
75 - 99.9%
100% (Enteral feeds are the sole source of nutrition)
Enteral feeds provide what percentage of your daily calorie needs?
0 - 24.9%
25 - 49.9%
50 - 74.9%
75 - 99.9%
100% (Enteral feeds are the sole source of nutrition)
0 - 24.9%
25 - 49.9%
50 - 74.9%
75 - 99.9%
100% (Enteral feeds are the sole source of nutrition)
Which method do you use to provide tube feeds to the consumer?(Check all that apply)
Select all that apply
Which method do you use to take tube feeds?(Check all that apply)
Select all that apply
Please describe 'Other' method of providing tube feeds
Are Enteral Feeds covered /reimbursed by insurance?
Yes, completely
Yes, partially
Not at all
Don't know
Yes, completely
Yes, partially
Not at all
Don't know
Please provide what percentage of the enteral feeds are covered/reimbursed by the insurance:
Does the consumer use an adapter (refer to the image below) with your feeding tube?
Yes No
Do you use an adapter (refer to the image below) with your feeding tube?
Yes No
Example image of an Adapter
How often does the consumer's connection come apart during feedings?
At each feeding
Daily
Weekly
Every other week
Monthly
Less than once a month
At each feeding
Daily
Weekly
Every other week
Monthly
Less than once a month
How often does your connection come apart during feedings?
At each feeding
Daily
Weekly
Every other week
Monthly
Less than once a month
At each feeding
Daily
Weekly
Every other week
Monthly
Less than once a month
How often does the consumer's tube get clogged?
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
How often does the consumer's tube get kinked?
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
How often does your tube get clogged?
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
How often does your tube get kinked?
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
In the last year, how many times has the consumer been treated for a skin infection around the tube insertion site?
Never 1 2 3 4 5 more than 5 times Never
1
2
3
4
5
more than 5 times
In the last year, how many times have you been treated for a skin infection around the tube insertion site?
Never 1 2 3 4 5 more than 5 times Never
1
2
3
4
5
more than 5 times
How often do you clean the end of the consumer's feeding tube (the connector)?
Multiple times a day
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
I don't clean the connector
Multiple times a day
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
I don't clean the connector
How often do you clean the end of your feeding tube (the connector)?
Multiple times a day
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
I don't clean the connector
Multiple times a day
Daily
3-5 times a week
1-2 times per week
3-4 times per month
1-2 times per month
Less than once a month
I don't clean the connector
What do you use to clean the connector?(Check all that apply)
Select all that apply
Describe 'Other' material that you use to clean the connector
Have you been diagnosed with COVID-19 (Coronavirus)?
Yes
No
Has your loved one been diagnosed with COVID-19 (Coronavirus)?
Yes
No
Did you experience any of the following symptoms?
Select all that apply
Did your loved one experience any of the following symptoms?
Select all that apply
Please mention the other symptoms
Yes
No
Was your loved one hospitalized?
Yes
No
During the COVID-19 pandemic, have you experienced any delays in healthcare?
Yes
No
During the COVID-19 pandemic, has your loved one experienced any delays in healthcare?
Yes
No
Please define the delays in healthcare
Select all that apply
Please mention other delays in healthcare
During the COVID-19 pandemic, have you experienced a delay in receiving supplies?
Yes
No
During the COVID-19 pandemic, has your loved one experienced a delay in receiving supplies?
Yes
No
Please define the delay in supplies
Select all that apply
Please mention the other delays in supplies
During the COVID-19 pandemic, have you experienced a worsening of your general health?
Yes
No
During the COVID-19 pandemic, has your loved one experienced a worsening of their general health?
Yes
No
Please define your answer to the above question
During the COVID-19 pandemic, have you experienced a worsening of your mental health?
Yes
No
During the COVID-19 pandemic, has your loved one experienced a worsening of their mental health?
Yes
No
Please define your answer to the above question
What is your specialty?(Check all that apply)
What is the location of your current occupation?(Check all that apply)
Describe Other (occupation location)
In which CONTINENT do you practice?
Northern America (includes Canada, USA, Central America and Carribean)
South America
Europe
Asia
Northern America (includes Canada, USA, Central America and Carribean)
South America
Europe
Asia
In which state/country do you practice/work?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon Belize Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Other
Please use the "Other" option if your practice country/state is not in the list. Thank you.
Please describe "Other" state/country:
In which country do you practice (South America)?
Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela
In which country do you practice (Europe)
Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Italy Kazakhstan Kosovo Latvia Liechtenstein Lithuania Luxembourg Malta Moldova Monaco Montenegro Netherlands North Macedonia (formerly Macedonia) Norway Poland Portugal Romania Russia San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Turkey Ukraine United Kingdom (UK) Vatican City (Holy See)
In which country do you practice (Asia)
Afghanistan Armenia Azerbaijan Bahrain Bangladesh Bhutan Brunei Burma Cambodia China Cyprus Georgia Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan North Korea South Korea Kuwait Kyrgyzstan Laos Lebanon Macau Malaysia Maldives Mongolia Nepal Oman Pakistan Palestine Philippines Qatar Saudi Arabia Singapore Sri Lanka Syria Taiwan Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen
In which City do you practice?
Do you physically place feeding tubes in your patients?
Yes No
What age group do you PLACE FEEDING TUBES in? (check all that apply)
Select all that apply
What type of feeding tubes do you place? (Check all that apply)
Gastric tube
Jejunal tube
Gastro-jejunal tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastric tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastro-jejunal tube
Naso-gastric tube
Naso-jejunal tube
Don't know/not sure
Gastric tube
Jejunal tube
Gastro-jejunal tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastric tube
Low-profile (Button, MIC-KEY, AMT, Skin-level device) gastro-jejunal tube
Naso-gastric tube
Naso-jejunal tube
Don't know/not sure
Which of the following age groups do you FOLLOW patients with feeding tubes: (check all that apply)
Select all that apply
At your institution, which techniques of enteral feeding tubes are available?
At your institution, who places naso-enteric (naso-gastric and naso-jejunal) tubes?
Select all that apply
At your institution, who places percutaneous enteral tubes?
Select all that apply
What percentage (estimated) of your tubes after discharge are: a. Gastrostomy tubes (percutaneous or surgically placed)
d. Low-profile gastrostomy (button)
e. Low-profile jejunostomy
h. Low-profile gastro jejunostomy
View equation Should equal to 100
Please provide an estimate of how many NEW home enteral patients do you see per year
0-10
11-24
25-49
59-74
75-99
100+
0-10
11-24
25-49
59-74
75-99
100+
Please provide an estimate of the number
Please provide an estimate of how many ONGOING home enteral patients do you manage per year
0-10
11-24
25-49
59-74
75-99
100+
0-10
11-24
25-49
59-74
75-99
100+
Please provide an estimate of the number
In your ADULT home enteral nutrition patients, what is the most common tube size utilized?
12 Fr
14 Fr
16 Fr
18 Fr
20 Fr
22 Fr
24 Fr
26 Fr
12 Fr
14 Fr
16 Fr
18 Fr
20 Fr
22 Fr
24 Fr
26 Fr
a. Dysphagia due to stroke/neurologic
b. Dysphagia due to head and neck cancer/UGI tract cancer
c. Cancer other than head and neck cancer
View equation Should equal to 100
Describe Other diagnosis in adults
In your PEDIATRIC home enteral nutrition patients, what is the most common tube size utilized?
5 Fr
6 or 6.5 Fr
8 Fr
10 Fr
12 Fr
14 Fr
16 Fr
18 Fr
20 Fr
22 Fr
24 Fr
26 Fr
5 Fr
6 or 6.5 Fr
8 Fr
10 Fr
12 Fr
14 Fr
16 Fr
18 Fr
20 Fr
22 Fr
24 Fr
26 Fr
a. Dysphagia due to stroke/neurologic
b. Dysphagia due to head and neck cancer/UGI tract cancer
c. Cancer other than head and neck cancer
View equation Should equal to 100
Describe Other diagnosis in pediatric patients
What percentage (estimated) of your patients uses the following formula types? a. Standard Polymeric or 1.5 with or without fiber
b. Specialty formulas (Protein enriched, semi-elemental peptide based, fish oil, renal, hepatic omega-3, etc.)
c. Concentrated formulas (2.0 kcal per ml)
d. Commercial Blenderized tube feeding
e. Homemade blenderized tube feeding
f. Combination of more than one formula type
Describe other formula(s) with percentages
What percentage (estimated) of your patients provide enteral feeds with the following methods? a. Bolus (push) via syringe
b. Bolus (gravity) via syringe
c. Gravity feeds (bag and tubing open to gravity)
e. Combination of more than one feeding method
a. Acute (less than 1 month)
b. Sub-acute (1 month to less than 3 months)
c. Chronic (3 months to less than 6 months)
d. Chronic (6 months to 12 months)
e. Prolonged (greater than 12 months)
View equation Should equal to 100
a. Acute (less than 1 month)
b. Sub-acute (1 month to less than 3 months)
c. Chronic (3 months to less than 6 months)
d. Chronic (6 months to 12 months)
e. Prolonged (greater than 12 months)
View equation Should equal to 100
What percentage of your ADULT HEN patients do you add a multi-vitamin?
What percentage of your PEDIATRIC HEN patients do you add a multi-vitamin?
On an average, HEN provides what percentage of the caloric needs of your ADULT patients?
0 - 24.9%
25 - 49.9%
50 - 74.9%
75 - 99.9%
100%
0 - 24.9%
25 - 49.9%
50 - 74.9%
75 - 99.9%
100%
On an average, HEN provides what percentage of the caloric needs of your PEDIATRIC patients?
0 - 24.9%
25 - 49.9%
50 - 74.9%
75 - 99.9%
100%
0 - 24.9%
25 - 49.9%
50 - 74.9%
75 - 99.9%
100%
a. Self-pay - Complete (100% self coverage)
b. Private insurance coverage (through employer or purchased insurance) - Complete coverage
b. Private insurance coverage (through employer or purchased insurance) - Partial coverage
c. Government insurance coverage - Complete coverage
c. Government insurance coverage - Partial coverage
View equation Should equal to 100
a. Self-pay - Complete (100% self coverage)
b. Private insurance coverage (through employer or purchased insurance) - Complete coverage
b. Private insurance coverage (through employer or purchased insurance) - Partial coverage
c. Government insurance coverage - Complete coverage
c. Government insurance coverage - Partial coverage
View equation Should equal to 100
a. Do you currently use BTF in your practice?
Yes No
b. Are you pro/against BTF?
Pro BTF Neutral Against BTF Pro BTF
Neutral
Against BTF
c. On a scale of 1-5 (5 being most comfortable), how comfortable do you feel advising patients on how to use BTF?
1 2 3 4 5
d. What percentage of your patients are able to meet their nutritional needs through BTF?
e. How likely are patients to develop complications with BTF compared to standard formula? (5 is most likely)
1 2 3 4 5
Peristomal infection requiring antibiotics
Tube clogging requiring intervention
Tube clogging requiring intervention
Other complications (please specify below)
Please specify the complication
Describe other symptoms that patients complain
Is mental health counseling routinely offered to your patients on enteral feeding.
Yes No
Have you ever heard of ENfit?
Yes No
Example images of ENfit and Legacy type connectors:
When and where did you hear about ENfit? (Date, place/conference/website)
Please enter as (Date, Place)
Has your practice transitioned to ENfit?
Yes No
Do you plan to transition to ENfit?
Yes No
When do you plan to transition to ENfit?
Today M-D-Y
Reason for not wanting to transition to ENfit
Please comment on what your institution is doing to prevent miss-connections if not transitioning to ENFit
Have any of your home enteral nutrition patients been diagnosed with COVID-19?
Yes
No
Of the COVID-19 positive patients, what percent of the patients experienced the following symptoms?
2. Respiratory symptoms (cough, shortness of breath, pneumonia, etc.) - percentage
3. GI symptoms (diarrhea, abdominal pain, nausea, etc.) - percentage
4. Other symptoms (please define other symptoms below) - percentage
Please define other symptoms
During the COVID-19 pandemic, have any of your HEN patients experienced a delay in health care?
Yes
No
Please define the delay in receiving health care
Select all that apply
Please define other delay in health care
During the COVID-19 pandemic, have any of your HEN patients experienced a delay in receiving supplies?
Yes
No
Please define the delay in receiving supplies?
Select all that apply
Please define other delay in supplies
During the COVID-19 pandemic, have any of your HEN patients experienced a worsening of their general health?
Yes
No
During the COVID-19 pandemic, have any of your HEN patients experienced a worsening of their mental health?
Yes
No
