Date Observed/Performed
Clerkship Emergency Medicine
Family Medicine Clerkship
Internal Medicine Clerkship
Obstetrics & Gynecology Clerkship
Pediatric Clerkship
Psychiatry Clerkship
Surgery Clerkship
Type of Visit Acute
Chronic
Wellness Visit
Is this patient new to YOU? Y/N
Supervisor (choose name from list)
Setting Clinic
Hospital
ER
Simulation
Specific Location (i.e. name of clinic/hospital) (text box)
Level of Involvement Minimal: Min. Pt. contact
Moderate:  Hx and/or PE
Full: Hx and PE + (DDx and/or Tx)
Patient Age 1-23 months
2-5 years
6-18 years
19-44 years
45-64 years
65+
Patient Gender M/F
Patient Race American Indian
Asian
Black
Hispanic/Latino
Pacific Islander
White
Other
Diagnosis 1st DX
2nd DX
3rd DX
Notes (text box)