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Standardized Patient Application Form

**This application does not constitute an offer of employment**

If you think that you may be interested in being a Standardized Patient for the University of Louisville Health Sciences Center, please complete the following questionnaire. Once we have had a chance to review the information, you may be invited to an informational session at which we will explain the program in detail. If you have questions prior to this time you may call me at 852-2367.

The University of Louisville School of Medicine employs standardized patients in the training and evaluation of medical students, residents, and other professionals. A Standardized Patient is a person who has been coached to accurately and consistently recreate the history, personality, physical findings, and emotional structure and response pattern of an actual patient isolated at a particular point in time. Standardized Patients (or simulators) are interviewed and examined (just as you would be by your family doctor) by male and female medical students. In the patient role, simulators may see several (1 to 12) students on a one-to-one basis during an evaluation session or there may be a group of medical students (4 to 7) working with you in a controlled teaching session.

Personal Information
Your name:
E-mail address:
Complete Address:
Home Phone:
Work Phone:
Employer:
Height:   Weight:      Number of Children:  
Marital Status:
Date of Birth (*required*):
Occupation (or former occupation if unemployed):




About You

How did you hear about the Standardized Patient Program?



What makes you interested in working as a Standardized Patient?



Describe your personality (in 10 words or less)



What special skills, abilities, or experiences do you feel you bring to this role?



Briefly describe your past experiences with and opinions about physicians and other medical care providers:




Patient Casting Information


What surgeries have you had? Please specify year performed, and size and location of scar.



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



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



What days of the week are you normally available to work?



What is the best time to reach you by phone?



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


MALES:    Are you interested in participating as a patient instructor in the male genital/rectal examination program?  Yes  No
 More Info
FEMALES:    Are you interested in participating as a patient instructor in the female pelvic and breast examination program?  Yes  No
 More Info