Simulated Patient Application
The Pennsylvania State University College of Medicine employs simulated patients in the training and evaluation of medical students, residents and other professionals. A Simulated/Standardized Patient is a person who has been coached to accurately recreate the history, personality, physical findings, and emotional structure and response pattern of an actual patient isolated at a particular point in time.
Simulated patients are interviewed and examined (just as you would be by your family doctor) by male and female medical students. In the patient role, simulators may see several (1 to15) students on a one-to-one basis during an evaluation session or there may be a group of students (4 to 7) working with you in a controlled teaching session.
If you think you may be interested in being a simulated patient for the Pennsylvania State University College of Medicine, please complete the following questionnaire and return it to:
Penn State College of Medicine
Attention: Stacey Carmo
Office of Medical Education, Mail Code H176
500 University Drive
P.O. Box 850
Hershey, PA 17033
Thank you for your interest!
Stacey Carmo RN, BSN
Standardized Patient Program Manager
««««««««««««««««««««««««««««««««««««««««
Name:Street Address:
City: / State: / Zip Code:
Date of Birth:
Occupation(or former occupation if retired):
Employer:
Home Phone: / Work Phone: / Cell Phone:
Email Address: / Marital Status:
# of Children: / Ages:
Height: / Weight: / Hair Color: / Eye Color:
Race/Ethnic Background:
Days/times/seasons available for work:
Are you a U.S. Citizen? □ Yes □ No
Do you have any chronic medical problems or conditions (such as high blood pressure, diabetes, arthritis, etc.) for which you are being or have been treated? If so, please specify:
Have you had any surgeries? If so, please specify (year performed, type, size and location of scar):
Do you have any other significant scars, irregularities, or handicapping conditions? (such as partial deafness, muscle weakness, heart murmur, etc.):
How did you hear about the Simulated Patient Program?
What makes you interested in working as a simulated patient?
Describe your personality (in 10 words or less):
What skills, abilities, or experiences do you feel you bring to this role? (bilingual, etc.)
Briefly describe your past experiences with and opinions about physicians and other medical care providers:
Males: Are you interested in participating as a patient instructor in the male genital/rectal examination program? Yes_____ No______
Need more information_____
Females: Are you interested in participating as a patient instructor in the pelvic
and breast examination program? Yes_____ No______
Need more information_____
Signature: ______Date: ______