Name: Date: Clinical and Professional Skills Respond to each item by reflecting on your ability level at the present time. Clinical Area Low Present Ability High Taking a chronological history 1 2 3 4 5 Doing a physical exam based on the patient's history 1 2 3 4 5 Doing a well child examination on infants and children 1 2 3 4 5 Assessing and presenting a patient's problems based on the history and physical you conducted 1 2 3 4 5 Developing a management plan and following up on a patient 1 2 3 4 5 Communicating and interacting with practice professional and support staff 1 2 3 4 5 Communicating and interacting with patients 1 2 3 4 5 Meeting expectations for professional behavior (e.g. appearance, dependability, confidentiality, etc.) 1 2 3 4 5 Clinical decision making in the face of uncertainty 1 2 3 4 5 Primary Care Practice Respond to each item by reflecting on your knowledge level at the present time. Practice Area Low Present Knowledge High Patient problems most commonly seen in a primary care practice 1 2 3 4 5 Procedures commonly performed in a primary care practice 1 2 3 4 5 Office operation and flow in a primary care practice 1 2 3 4 5 Roles and responsibilities of professional and support staff in the practice 1 2 3 4 5 Quality assurance procedures 1 2 3 4 5 Community Health Care Respond to each item by reflecting on your knowledge level at the present. Health Care Area Low Present Knowledge High Presence of health care providers in the community and the services they offer 1 2 3 4 5 Presence of public and private agencies and organizations (other than direct care providers) that make up the health care system in the community and the services they offer 1 2 3 4 5 Quality assurance implemented by hospitals and other health care providers 1 2 3 4 5 The nature and extent of health care issues and concerns faced by the community 1 2 3 4 5 The extent to which the community's health care needs are being met 1 2 3 4 5 What do you believe will be the value and contribution of the Rural Clerkship experience to your overall medical education? Do you plan to select a primary care speciality? Definitely Probably Unlikely Definitely Not Not Sure Do you plan to practice in a rural area? Definitely Probably Unlikely Definitely Not Not Sure Did the Rural Clerkship experience influence your future practice plans? Explain below. Definitely Probably Unlikely Definitely Not Not Sure
