Chronic Pain ECHO Network Waitlist Enrolment Form

Question Title

* 1. First name

Question Title

* 2. Last name

Question Title

* 3. Email address

Question Title

* 4. Mobile number

Question Title

* 5. What is your profession? Please tick one option

GP Specialist

Exercise Physiologist

Nurse or Nurse Practitioner

Occupational Therapist

Osteopath

Chiropractor

Pharmacist

Physiotherapist

Clinical Psychologist

Social Worker

Sport Physician

Other (please specify)

Question Title

* 6. How many years have you been in practice? Please tick one option

<2 years

2-5 years

6-10 years

>10 years

Question Title

* 7. How many patients with chronic pain have you managed in the past 12 months? Please tick one option

1 - 5

6 - 10

11 - 30

>30

Question Title

* 8. How many patients with workplace injuries managed under the workers compensation scheme have you managed in the past 12 months? Please tick one option.

1 - 5

6 - 10

11 - 30

>30

Question Title

* 9. What is the name of your primary workplace?

Question Title

* 10. What is your primary workplace suburb?

Question Title

* 11. Is your primary work location classified as:

Metropolitan SA

Regional SA

Remote SA

Question Title

* 12. Would your work environment be described as

Solo practice

Team of practitioners from the same clinical discipline

Team of practitioners of different clinical disciplines

Question Title

* 13. What would you like to gain from joining the Chronic Pain ECHO Network?

Question Title

* 14. How did you hear about the Chronic Pain ECHO Network?

SAPMEA

Adelaide PHN

Country SA PHN

SA Health / Wellbeing SA

Personal communication from a colleague

ReturnToWorkSA

RACGP

Other professional associations. Please specify

Other (please specify)

One of the benefits of the network is to obtain feedback from the multidisciplinary panel about how best to manage particular patients with chronic pain. We offer support to participants to develop a case presentation

Question Title

* 15. Would you be interested in presenting a case?

Yes

Unsure

Question Title

* 16. If you are a RACGP member and would like to claim 40 points for participating in this Peer Group Learning Accredited Activity (Reviewing Performance Category 1), please provide us with your RACGP membership number.

Please note: you must participate in the initiation and review meetings (10 mins) as well as a minimum of 4 sessions to be eligible for the 40 CPD points. RACGP members who attend fewer than 4 sessions, will receive an attendance certificate to self-claim Cat 2 points.

Question Title

* 17. If you are an ACRRM member and would like to claim points for participating in this Case Discussion Activity (Performance Review Category), please provide us with your ACRRM membership number.