Standardized Patient Application Form

The information requested below is used only to assist in case selection, not in determining engagement as a standardized patient. All information is kept in strict confidence.

Last Name First Name MI

Date of Birth: mm/dd/yyyy

Address

City State Zip

Home Phone Work Phone Fax

E-mail Address

Employer

Occupation Work Hours
Education

List the days/times you could participate in the SP Program.

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

2.  Have you ever been a standardized patient before?  Yes   No

3.  If you answered no to question 2, please proceed to question 4.  

If you answered yes to question 2, please answer the following questions:

In what program/university did you participate?

When did you participate?  

In what type of exam did you participate?  

What cases did you portray?

4.  Why are you interested in participating in the SP Program?

5.  Please describe your personality.

6.  Please check the character types you could adequately portray.

anxious articulate athletic
authoritative bored calm
confident depressed exuberant
exuberant fidgety dying of a terminal disease
friendly heavy smoker in great pain
large-boned manual laborer muscular
outgoing overweight pale skin
petite physically inactive poor verbal skills
retiring slow-speaking submissive
talkative tanned skin underweight
professional withdrawn scared

7.  List all languages you speak well.

8.  Please check the exams you would be willing to participate in:        

non-invasive physical exam only
history only
history and non-invasive physical exam

9.  What is your ethnic origin?  

10.  What is your gender? Male    Female

11.  What is your height?     Weight?  

12.  Do you smoke? No  Occasionally  Regularly   Frequently

13.  If you have any distinguishing marks, birthmarks, scars, tattoos, etc., please specify what and where.

14.  If you have had any surgeries, please specify what type and the size and location of the scar.

15.  Please indicate which (if any) of the following medical conditions you have/have had.

asthma stroke diabetes tuberculosis
COPD heart attack arthritis high blood pressure
HIV+ heart failure depression Hepatitis-B

16.  If you checked any of the above, please indicate below when it was diagnosed, how it was treated, and how long you have been experiencing symptoms.

17.  Please indicate whether you have ever had any of the medical conditions below.

migraine headaches gallstones chest pain
other headaches kidney stones back pain

18.  If you checked any of the above, please indicate below when it was diagnosed, how it was treated, and how long you have been experiencing symptoms.

19.  Do you currently have any of the following physical conditions?

abnormal lung sounds joint damage abnormality of retina
abnormal heart sounds enlarged thyroid or thyroid nodule abnormal blood vessels
heart murmur nerve damage muscle weakness

20.  If you checked any of the above, please indicate below when it was diagnosed, how it is treated, and how long you have been experiencing symptoms.

21.  In order to draw from your real-life experiences, please give information about any close friends or relatives who have had significant health problems or diseases.

Questions and/or concerns may be directed to Eugenia Greenfield at 713-798-7952 or eugeniag@bcm.edu.
Thank you for your cooperation.