FPM clinical case study
The clinical case study must be submitted as a word document in the format outlined in, Preparation of the clinical
case study. The first page of the cover sheet will be removed before the case study is allocated to a member of the
panel of examiners.
Please ensure all instructions included in the Preparation of the clinical case study have been addressed when
submitting your case study.
Trainees are reminded that collecting information about patients has important privacy implications. In collecting
and using any patient information it is your responsibility to ensure that all privacy obligations are met, and any
necessary consent obtained. Only de-identified information should be routinely stored. If any identifying information
is recorded in the learning portfolio, or other material submitted to the Faculty, please ensure that you (or your
hospital's privacy statement) address this issue or that your patient has consented.
1. Personal information
College ID: __ / __ / __ / __ / __
Name: __________________________________________________________________________
2. Training details
Training site: __________________________________________________________________________
Name of SoT / PDS supervisor:____________________________________________________________
3. Trainee and SoT / PDS supervisor declaration
Trainee signature: ________________________________________ Date: _________________________
Supervisors Signature: ____________________________________ Date: __________________________
Please send your clinical case study including this cover sheet to:
Faculty of Pain Medicine
PO Box 6095
ST KILDA ROAD CENTRAL
VIC 8008 AUSTRALIA
FPM clinical case study cover sheet August 2015
painmed@anzca.edu.au
fax: +61 3 9510 6786
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FPM clinical case study
(Note: please do not the mention the name of the trainee, supervisor or training site on this page)
3. Case study details
Title of clinical case study: ________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
4. Statement of involvement in the management of the patient
_________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
5. Word Count (2500 – 5000 words): ________________________________________________________
6: Keywords
_________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
7. SoT / PDS supervisor to indicate the methodology used by the trainee for sourcing references:
_________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
FPM clinical case study cover sheet August 2015
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