Book a Standardized Patient / Model
Contact Information
First Name:
Last Name:
Phone Number:
Email:
Simulation Date/Time
Start Date:
End Date:
Start Time:
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End Time:
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:00
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:45
Simulation Information
NAIT Program:
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Advanced Care Paramedic
Biomedical Engineering Technology
Combined Lab & X-ray Technology
Dental Assisting
Dental Technology
Denturist Technology
Diagnostic Medical Sonography – General
Diagnostic Medical Sonography – General & Cardiac
Disaster and Emergency Management
Interprofessional Education
Magnetic Resonance Imaging, 1st Discipline
Medical Laboratory Assisting
Medical Laboratory Technology
Medical Radiologic Technology
Occupational Health and Safety
Personal Fitness Trainer
Primary Care Paramedic
Respiratory Therapy
Veterinary Medical Assistant
Veterinary Technology Program
Other
Other Program:
Room Number
Course Code:
Number of Standardized Patients/Participants
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9
10
Patients/Participants Information
Provide Additional Actor/Actress Profile Information:
Patient 1 Gender:
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Male
Female
Other
Patient 1 Age Range:
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18-24
25-39
40-54
55-64
Over 65
Patient 2 Gender:
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Male
Female
Other
Patient 2 Age Range:
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18-24
25-39
40-54
55-64
Over 65
Patient 3 Gender:
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Female
Other
Patient 3 Age Range:
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18-24
25-39
40-54
55-64
Over 65
Patient 4 Gender:
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Male
Female
Other
Patient 4 Age Range:
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18-24
25-39
40-54
55-64
Over 65
Patient 5 Gender:
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Male
Female
Other
Patient 5 Age Range:
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18-24
25-39
40-54
55-64
Over 65
Patient 6 Gender:
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Male
Female
Other
Patient 6 Age Range:
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18-24
25-39
40-54
55-64
Over 65
Patient 7 Gender:
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Male
Female
Other
Patient 7 Age Range:
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18-24
25-39
40-54
55-64
Over 65
Patient 8 Gender:
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Male
Female
Other
Patient 8 Age Range:
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18-24
25-39
40-54
55-64
Over 65
Patient 9 Gender:
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Male
Female
Other
Patient 9 Age Range:
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18-24
25-39
40-54
55-64
Over 65
Patient 10 Gender:
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Male
Female
Other
Patient 10 Age Range:
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18-24
25-39
40-54
55-64
Over 65
Additional Comments
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