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5.a Physician Pre-visit Questionnaire Q2

Email:

joanne.peat@usask.ca

Website:

www.pepsask.ca

Physician Pre-visit Questionnaire

Please complete – BY PRINTING LEGIBLY FOR DATA ENTRY PURPOSES – and

return this questionnaire within three (3) weeks to:

Practice Enhancement Program

CPL, U of S, Box 60001, RPO University

Saskatoon, SK S7N 4J8

A.

Demographic Data

1.

Surname: _______________________ 2. Given Names: ___________________

3. Date of Birth: Day ____ Month ____ Year ____ 4.  Female

 Male

5.

Office Address:

6.

Telephone: Office _________ 7. Home __________ 8. FAX: _______________

9. Do you have access to the Internet?

Yes  No 

10. Do you use Email?

Yes  No 

11. If so, what is your E-mail address? ____________________________________

12. What is your preferred mode of communication? Mail  Email  Fax 

13. Year of Graduation (medical school) ____________________________________

14. Medical Degree from University of _____________________________________

Location of University _______________________________________________

15.

If you are not engaged in clinical practice please sign and return this form.

Signature _______________________________ Date _________________________

Physicians Enhancing Medical Practice