Elective "Generic" Logbook

Name:
Elective:

If Extramural or IDE, enter identifying course number and name here:

Department:
Elective End Week:

Date Patient Seen:

Patient's Age:    Years      Months

Patient's Gender:

Location: 
Chief Complaint:
Primary Diagnosis:
Diagnosis 2:
Diagnosis 3:
Procedure:

Procedure Role:

Problem List:

Notes/Comments:

 

Jean Afflerbach, Web Master
Revised: September 06, 2012