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Personal Information
First name
*
Last name
*
Male/Female
Street Address
City
Province or Territory
Postal Code
Email
*
Phone
Fax
Office
Office Location
*
Urban
Rural
Type of Practice
*
Solo
Group
Primary Language used in practice
*
English
French
Other
Practice Characteristics
All ages well represented?
*
Yes
No
Please rate your level of activity for the following clinical activities:
Paediatrics
Prominent
Average
Infrequent
None
Geriatrics
Prominent
Average
Infrequent
None
Psychotherapy/Mental Health Counseling
Prominent
Average
Infrequent
None
Sports Medicine
Prominent
Average
Infrequent
None
Occupational Health
Prominent
Average
Infrequent
None
Obstetrics
Prominent
Average
Infrequent
None
If you provide OB care, what is the description of your activity:
Frequent
Infrequent
None
Average number of pregnant women you care for per year
Active in-Hospital Care
Frequent
Infrequent
None
Supportive Hospital Care
Frequent
Infrequent
None
Newborn Care
Frequent
Infrequent
None
Nursing Home Visits
Frequent (more than 3/week)
Infrequent (1-3/week)
None
Shifts in the ER
Frequent
Infrequent
None
House Calls
Frequent (more than 3/week)
Infrequent (1-3/week)
None
Palliative Care
Frequent (following 1 or more patients)
Infrequent
None
Office Procedures
Frequent (daily)
Infrequent (weekly)
None
After House Coverage
On call for own group
Sign out to coverage service
Other
Do you have active hospital privileges?
Yes
No
If yes, what hospital(s)?
Have you had students/residents in your practice before?
Never
Occasionally
Frequently
What characteristics would make your practice a good location for a student to learn?
Submit
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