Patient Educator Group application form Mr / Mrs / Ms / Miss / Dr / Other (please specify) Name: Address: address: number: Home Mobile Date of Birth: Gender: Ethnicity: Mobility issues and/or sensory impairment (if yes do you require any aids please state): – Do you have a condition that requires the use of oxygen: Yes No Dietary requirements (please state): Preferred method of transport? Own Public Taxi (please complete if you would like to be involved as a patient) Patients Medical condition: detail any long term health conditions or disabilities that you wish to be (please involved in teaching sessions for) Will you be accompanied on the day eg by a partner or carer? Yes No Carers (please complete if you would like to be involved as a carer) Relationship to the person you care for: What is their date of birth? What is their medical condition? (please circle appropriate answer) Teaching sessions I am interested in History taking/Patient experience (a student will take your medical history and Yes No Maybe explore the impact your illness has on you and your family; or a question and answer session with a small group of students) Physical examination (a simple physical examination based on your condition, Yes No Maybe students will be supervised at all times) Yes No Maybe
Patient Educator Group application form Mr / Mrs / Ms / Miss / Dr / Other (please specify) Name: Address: address: number: Home Mobile Date of Birth: Gender: Ethnicity: Mobility issues and/or sensory impairment (if yes do you require any aids – please state): Do you have a condition that requires the use of oxygen: Yes No Dietary requirements (please state): Preferred method of transport? Own Public Taxi Patients (please complete if you would like to be involved as a patient) Medical condition: (please detail any long term health conditions or disabilities that you wish to be involved in teaching sessions for) Will you be accompanied on the day eg by a partner or carer? Yes No Carers (please complete if you would like to be involved as a carer) Relationship to the person you care for: What is their date of birth? What is their medical condition? Teaching sessions I am interested in (please circle appropriate answer) History taking/Patient experience (a student will take your medical history and explore the impact your illness has on you and your family; or a question and answer session with a small group of students) Yes No Maybe Physical examination (a simple physical examination based on your condition, students will be supervised at all times) Yes No Maybe Yes No Maybe
applicationform-cmb-approved-brightmed-update-jw-oct2018-v2.docx