Dementia ECHO 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? GP Specialist Non- GP Specialist (please also select other and specify) Nurse IMG Junior Doctor Pharmacist Allied Health Professional (please also select other and specify) Other (please specify) Question Title * 6. Workplace name Question Title * 7. Workplace suburb Question Title * 8. Is your work location classified as: Metropolitan SA Regional SA Remote SA Question Title * 9. 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 * 10. Do you have a patient case you would like to discuss at the network? Yes No Unsure Question Title * 11. What would you like to gain from joining the Dementia ECHO? Question Title * 12. For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas: Dementia subtypes and diagnosis Non-pharmacological management of dementia symptoms Younger onset dementia Dementia services and support in newly diagnosed patients Dementia and driving Dementia and sexuality SACAT and Advance Care Directives Question Title * 13. How did you hear about the Dementia ECHO Program? SAPMEA Adelaide PHN Country SA PHN SA Health / Wellbeing SA GP Integration Unit Direct email invitation Social media Word of mouth Other (please specify) Question Title * 14. If you are an RACGP member please provide your RACGP ID. Participants will receive 1 CPD hour under the Reviewing Performance category with RACGP for each session attended.GPs presenting a case for discussion, will receive 1 CPD hour under the Measuring Outcomes category (to be self-claimed) Question Title * 15. If you are an ACRRM member please provide us with your ACRRM membership number.Participants will receive 1 CPD hour under the Reviewing Performance category with ACRRM for each session attended. Question Title * 16. Would you like to subscribe to our fortnightly newsletter? Yes No, I am already subscribed No, I am not interested Submit response >>
