College Of Medicine
University of Illinois Urbana-Champaign

Title of page

COMPLEMENTARY, ALTERNATIVE AND INTEGRATIVE MEDICINE

Observership Visit Form

  • Please Note: Do not include any information that would be so distinctive as to allow identification of the patient. The information you will transmit here is not a component of the patient's medical record, and careful attempts must be taken to prevent any identification of the patient or patients discussed.

  • Once this report is submitted, it cannot be deleted. Please check it carefully before submitting.

  • Your Report of Visit will be added to your record and may be shared with your Preceptor.

  • Before submitting this form, print a copy for your records.

  • You must click the "Submit Report Of Visit" button at the bottom when finished.

*Required fields

*Last Name:       *First Name:
*University NetID: *University E-mail:
University NetID: It is NOT the UIN #. If you need to look up your netid, please go here: http://webtools.uiuc.edu/ows/PH. The netid is found in the first field called "alias".

*Date of Visit: (i.e., 1/1/2007)

*Place of visit
If "Other", list here:

*Who was your preceptor?
First Name: Last Name:

Approximately how many hours did you spend with your preceptor?

What activities did you carry out during this visit? (Select as many as apply)
Observe
Talk to patient (elicit part of Hx)
Watch procedure
Discuss patient with preceptor
Observe provider other than preceptor
Other: describe briefly in box below
      If "Other", provide description of activities here:
      

Briefly describe the feelings of provider, patient, and yourself in this clinical encounter.
      

If you have further comments, please write them here:
      

  • Print a copy before submitting for your records.

  • Once this report is submitted, it cannot be deleted. Please check it carefully before submitting.

  • Your Report of Visit will be added to your record and may be shared with your Preceptor.

  • You must click the "Submit Report Of Visit" button at the bottom when finished.

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