Standardized Patient Data Sheet

 

 

To be completed by potential SP

A standardized/simulated patient (SP) is a person who has been coached to accurately and consistently recreate the history, personality, physical findings, emotional structure and response pattern of an actual patient isolated at a particular point in time. UAMS employs SPs in the training and evaluation of medical students, residents and other health care professionals. As an SP, you will be interviewed and examined (just as you would be by your own doctor) by male and female health professionals students. In the patient role, you may work with students in a one-on-one basis, or with a large group of students in a controlled teaching session.

Please complete the following information so we can add you to our Standardized Patient Data Base. Personal details such as ethnic background, date of birth, height/weight, and other physical or historical factors can be used in matching SPs to available cases. A recent snap shot of yourself may also help us match you to a case. Mail form to: Standardized Patient Program, 4301 W. Markham St., SLOT 735, Little Rock, AR 72205-7199.

[FrontPage Save Results Component]

 

Name:  

Social Security Number:

Complete Mailing Address: 

E-mail Address: 

Date of Birth (M/D/Y):

Height:   Weight:

 

Race/Ethnic Background: 

Home Phone:

Marital Status:   Occupation:

Number of Children:   Work Phone:

Employer:

1. How did you hear about the Standardized Patient Program?

 2. What makes you interested in working as an SP? 

 

3. Describe your personality (10 words or less): 

 

 4. What special skills/abilities/experiences do you feel you bring to this role? 

 

 5. Briefly describe your past experiences with, and opinions of, physicians and other medical care providers: 

 

 6. What, if any, surgeries have you had? 

 

7. Briefly describe any scars, irregularities, or handicapping conditions (such as partial deafness, muscle weakness, heart murmur, etc.) that you have:

 

 

8. Do you have any chronic medical problems or conditions (such as high blood pressure, diabetes,arthritis, etc.) for which you are being or have been treated? (Describe)

 

 

9. What days of the week will you normally be available for work?

 

10. Please list any other information you feel would be helpful to us:

 

11. Would you be willing to be a live "physical" model?

 

   yes no need more information

12. MALES: Are you interested in participating as a patient instructor in the male      genitourinary/rectal examination program?

  yes no need more information

13. FEMALES: Are you interested in participating as a patient instructor in the female pelvic or breast examination programs?

Pelvic exam program: yes no need more information

Breast exam program: yes no need more information

 Signature: Date:

 

  This page was last updated on March 13, 2002