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			<h1 style="margin-top:0px;">We'd Like to Hear From You!</h1>
        
		
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                            <tr><td colspan="2">The Low Back Pain Material provided on this site, has been developed with input from practicing family physicians, researchers, and our partner organizations. We would like to continue to provide you with up to date materials in this area. As such, we need to know from you if you find the material useful and how you are using the material in practice.

Please fill in the below form which refers to the LOW BACK PAIN MATERIAL available through the Resources section of this site. You may have also received some of this material in hard copy.

We thank you for taking the time to provide us with your feedback.

Note: You can select more than one option in the first two questions by holding down your Ctrl key. </td></tr>
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	<tr><td valign="top" class="displayFieldLabel">Which of the following best describes you?:&nbsp;<span class="requiredField">*&nbsp;</span></td><td valign="top" class="displayFieldContents">
	<select name="description" size="10" multiple>
		
			<option value="Physician">Physician</option>
		
			<option value="Nurse">Nurse</option>
		
			<option value="Physiotherapist">Physiotherapist</option>
		
			<option value="Occupational Therapist">Occupational Therapist</option>
		
			<option value=" 	Chiropractor">Chiropractor</option>
		
			<option value="Other Health Care Professional">Other Health Care Professional</option>
		
			<option value="Researcher">Researcher</option>
		
			<option value="Health Administrator">Health Administrator</option>
		
			<option value="Other">Other</option>
		
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			<option value=" 	Solo Practice"> 	Solo Practice</option>
		
			<option value="Group Practice">Group Practice</option>
		
			<option value="FHN / FHG / FHT">FHN / FHG / FHT</option>
		
			<option value="Hospital">Hospital</option>
		
			<option value="Academic">Academic</option>
		
			<option value="Administration">Administration</option>
		
			<option value="Other">Other</option>
		
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	<tr><td valign="top" class="displayFieldLabel">Have you used POCKET Low Back Pain Material in your practice? :&nbsp;<span class="requiredField">*&nbsp;</span></td><td valign="top" class="displayFieldContents" nowrap>
	
		
			<input name="used" type="radio" value="Yes" >Yes<br>
		
			<input name="used" type="radio" value="No" >No<br>
		
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	<tr><td valign="top" class="displayFieldLabel">Will you use POCKET Low Back Pain Material in your practice? :&nbsp;<span class="requiredField">*&nbsp;</span></td><td valign="top" class="displayFieldContents" nowrap>
	
		
			<input name="will_use" type="radio" value="Yes" >Yes<br>
		
			<input name="will_use" type="radio" value="No" >No<br>
		
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	<tr><td valign="top" class="displayFieldLabel">What material have you used? Or will you use? :&nbsp;</td><td valign="top" class="displayFieldContents">
	
		
			<input name="materials" type="checkbox" value="CD-Rom: 3 minute back exam ">CD-Rom: 3 minute back exam <br>
			
			
			<input name="materials" type="checkbox" value="Chronic Back Pain Summary ">Chronic Back Pain Summary <br>
			
			
			<input name="materials" type="checkbox" value="Patient Booklet: So Your Back Hurts ">Patient Booklet: So Your Back Hurts <br>
			
			
			<input name="materials" type="checkbox" value="Prescription Pad ">Prescription Pad <br>
			
			
			<input name="materials" type="checkbox" value="WSIB Guide and Phone Numbers ">WSIB Guide and Phone Numbers <br>
			
			
			<input name="materials" type="checkbox" value="Yellow/Red Flags Card ">Yellow/Red Flags Card <br>
			
			
			<input name="materials" type="checkbox" value="Website: www.pocketdocs.ca ">Website: www.pocketdocs.ca <br>
			
			
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	<tr><td valign="top" class="displayFieldLabel">How will you use them? :&nbsp;</td><td valign="top" class="displayFieldContents">
	
		
			<input name="how_use" type="checkbox" value="In my practice ">In my practice <br>
			
			
			<input name="how_use" type="checkbox" value="As a teaching tool ">As a teaching tool <br>
			
			
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