“Mommy, be my doctor” Personalization Questionnaire "Mommy, be my doctor" Participant Questionnaire My goal of this course is to be as tailored to your specific and current needs as possible, within my scope of teaching. In order for me to better facilitate all members of this workshop, please answer the following as detailed as possible and submit this form to me as soon as possible. First Name * Last Name * Email Address * How educated are you on the topic of anatomy and pathophysiology? ("Not at all educated on this topic" is perfectly fine. You're still in the right class). * Not at all educated on this topic Sort of educated on this topic Educated on this topic Very well educated on this topic Please elaborate: Why are you taking this course? Please be as specific as you can. * What are the top three things you hope to get out of this 6-week period? * What issues in yourself, your spouse, or your child, are you looking to resolve? * What diseases, or types of diseases, are in your family line? (Please include your spouses family line, too). * Are you willing to share your situation out loud in class for us to use your specific circumstances to teach the class to overcome similar circumstances? * Yes No This class will be taped and used for further teaching. Do I have permission to share the tape of you exclusively for educational purposes? * Yes No Submit
