Curtin Medical School: simulated patient expression of interest

First name:*

Last name:*

Email:*

Main contact number:*

Alternative number:

Preferred contact method:*
PhoneEmail

I am willing to take part in scenarios involving:*
History takingPhysical examinationBoth

Year of birth*

Gender*

Weight (kg)

Height (cm)

Occupation

Main language spoken at home*

Other language/s spoken at home

Do you identify as:
AboriginalTorres Strait IslanderBoth

How would you rate your general health?*
GoodFairPoor

Do you have a disability, impairment or long term medical condition?*
YesNo

If yes, is your condition likely to impact your ability to participate as a simulated patient?
YesNoNot sure

Additional information:

Simulated patients are needed for sessions in which medical students may be taught or assessed. Physical signs are many and varied, a few examples include:

I am willing to take part in scenarios requiring a simulated patient with physical signs*
YesNo

My physical sign is:

Your GPs contact details, including full name, email and telephone:

Please note: Due to examination equity and integrity protocols as a simulated patient with real psychical signs, if, during the academic year you have assisted with general teaching specifically relating to your psychical sign you will not be invited to assist with Curtin Medical School end of year examinations.

Do you have previous acting or simulated patient experience?:*
YesNo
Previous acting experience or experience acting as a simulated patient is not required. However, if you have any experience this can assist with our planning and scheduling for specific sessions.

If yes, please provide details:

Are there any specific days / times you are NOT available?:*
YesNo

If yes, please provide details:

Conflict of interest: Do you know of any friends or relatives who are currently studying medicine at Curtin University?:*
YesNo

If yes, please provide details:

Vehicle registration (required for parking allocation)*
Curtin University is well serviced by public transport. However, if you require parking to attend a simulated patient session, please provide your vehicle registration number so parking fees can be pre-paid by Curtin Medical School. Please note, car parking availability can be limited and may be located some distance from the Curtin Medical School building, so plan your trip accordingly. If required, ACROD bays are located in close proximity to the Curtin Medical School building.

Special dietary requirements

Please tell us how you heard about Curtin Medical School’s Simulated Patient program:

Personal information collected is handled in accordance with the Australian Privacy Principles. Further information is available on Curtin University’s privacy webpage.