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Interventional Pain Management CME Certificate
Full Name, Degree (Example: John Smith, MD)
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Today's Date
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Enter your email address for CME/CE certificate delivery.
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Was the information presented in this activity biased and/or compromised by commercial support?
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Yes, it WAS biased and/or compromised by commercial support.
No, it WAS NOT biased and/or compromised by commercial support
If you felt like the information was biased and/or compromised by commercial support, please explain.
To what degree did this activity meet the learning objectives?
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Strongly Agree
Agree
Disagree
Strongly Disagree
Learning Objectives
(1) Identify common chronic pain conditions that cause low back pain.
(2) Recognize challenges associated with managing Chronic Pain
(3) Discuss evidence based minimally invasive interventions available for chronic pain patients.
(4) Examine appropriate minimally invasive interventions to help patient population suffering with Chronic Low Back Pain.
Please choose the best answer for each of the following.
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Strongly Agree
Agree
Disagree
Strongly Disagree
This activity provided new information to you.
Strongly Agree
Agree
Disagree
Strongly Disagree
The educational approach was conducive to your learning experience.
Strongly Agree
Agree
Disagree
Strongly Disagree
The information presented is applicable to your clinical practice.
Strongly Agree
Agree
Disagree
Strongly Disagree
The information presented will help you improve patient outcomes.
Strongly Agree
Agree
Disagree
Strongly Disagree
This activity increased my kowledge, competence, and/or will improve my performance in my practice.
Strongly Agree
Agree
Disagree
Strongly Disagree
I intend to implement changes in my practice based on the information presented.
Strongly Agree
Agree
Disagree
Strongly Disagree
If you plan to implement changes in your practice, check ALL the changes you plan to apply.
Differentiate and diagnose back pain.
Treat and manage back pain.
Utilize interventional pain management techniques on a case-by-case basis.
Are there any barriers that would keep you from implementing the practice paradigms discussed in this activity?
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No perceived barriers.
Lack of evidence-based guidelines.
Lack of applicability of guidelines to my current practice and/or patients.
Lack of time.
Organizational/Institutional.
Insurance/Financial.
Patient Adherence/Compliance.
Treatment related adverse events.
Of the patients you will see in the next week, about how many will benefit from the information you learned by participating in this activity?
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1-10
11-25
26-50
>50
How do you rate Dr. Gupta's delivery of this education?
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Excellent
Very Good
Average
Needs Improvement
Claim Credit
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I certify that I have participated in the number of hours (0.5 hours chosen below) of this educational activity and request a CME certificate indicating that number of credits. I will claim only the total number of hours for which I participated.
The number hours you participated in this activity.
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0.5
What is your specialty (Ex. Family Practice, Neurology, etc)
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How many years have you been in practice?
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<10
10-20
21-30
>30
How many days a week do you see patients?
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0-1
2-3
4-5
6-7
How many patients do you typically see per day?
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0-10
11-20
21-30
31-40
>40
What is your practice like?
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Solo or small group (1-5 providers)
Large Group (>5 providers)
Government Owned Facility/Clinic
Retired/Not Seeing Patients
Other (please specify)
Other (please specify)
Overall comments on this activity.
Mailing Address
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City
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State
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Zip Code
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Phone Number
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American Chronic Pain Association ● 11937 W. 119th Street, Suite 216, Overland Park, KS 66213