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IMPACT Clinical Summary Form

This form is to be used by GPs to report on each consultation remunerated under the IMPACT Program.

Note: Alternatively, you can download our interactive PDF version of this form.


GP details

Patient details

First name
Last name
(This is the reason for your patient presenting today.)
Patient consultation type
(select all that apply)
Consultation remuneration eligibility check

Patients must be:

  • 18 years of age and over,
  • covered by a QBE CTP policy,
  • have a current experience of pain,
  • be within 3 months of injury onset,
  • be at high-risk of an opioid prescription but not be dependent on opioid medication for consultations to be remunerated.
Eligibility criteria met

Assessment of patient

Check which domains are of concern for this patient, which domains you made a referral to another provider for, and which domains you have recommended patient active self-management for [check all that apply]
Harmful structural contribution
Social functioning
Occupational functioning
Other mental health
Physical activity
Cigarette smoking
Recreational drug use



Was an opioid prescribed for this patient in this consultation?
Have you established with the patient a maximum dose and timeframe for opioid use?
Was another schedule 8 medication prescribed for this patient in this consultation?
Is the patient currently taking an opioid medication (that was not prescribed in this consultation)?
Does the patient currently have a prescription for medicinal cannabis or cannabinoids?
Have you checked ScriptCheckSA for opioid prescriptions for this patient?
If there are issues of opioid dependence with this patient, the consultations for this patient are not eligible for remuneration. [https://www.scriptcheck.sa.gov.au]

Program Requests

Would you like to request a case consultation with the program’s pain management specialist in relation to this patient?
Would you like to request case coordination support for this patient?
If yes please also advise the patient of your request.