top of page

Preceptor Profile Form

Personal Information

Male/Female

Office

Office Location
Type of Practice
Primary Language used in practice

Practice Characteristics

All ages well represented?

Please rate your level of activity for the following clinical activities:

Paediatrics
Geriatrics
Psychotherapy/Mental Health Counseling
Sports Medicine
Occupational Health
Obstetrics
If you provide OB care, what is the description of your activity:
Active in-Hospital Care
Supportive Hospital Care
Newborn Care
Nursing Home Visits
Shifts in the ER
House Calls
Palliative Care
Office Procedures
After House Coverage
Do you have active hospital privileges?
Have you had students/residents in your practice before?
bottom of page