Peer to Practice Question & Clinical Case Submission Form

Thanks for contributing your questions/ clinical cases

If you are submitting a clinical case for review, please ensure you are able to attend the live session to answer any clarifying questions about the case

Note: not all questions/ cases will be reviewed. Incomplete submissions may be rejected

Peer to Practice: Clinical Herbal Mentorship Question Submission Form

Thanks for contributing your questions/ clinical cases If you are submitting a clinical case for review, please ensure you are able to attend the live session to answer any clarifying questions about the case Note: not all questions/ cases will be reviewed. Incomplete submissions may be rejected

Name

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Phone(Required)

Email(Required)

I am submitting:(Required)

A clinical question I would like answered

A case for clinical review

Session Date:(Required)

Level of Clinical Experience:(Required)

Seasoned Practitioner (> 3 years in practice)

New Practitioner (< 3 years in practice)

Student

Other (please specify)

Please describe your level of clinical experience:

Clinical Questions

Clinical Questions:

Please enter your clinical questions.

Case Submission Template

Patients Age

Patients Sex

Primary Complaint(s) at Intake

Secondary Complaints/ Comorbidities

Medications

Family History

History of Present Condition

Please include approximate dates of any diagnoses

Current Signs and Symptoms

Include findings of any physical exams

Habits & Substance Use

Nutrition & Diet

Movement & Exercise

Findings on Lab Work/ Other Testing

Current Supplements

Please indicate dosage and length of time taking

Current Herbal Prescriptions

Please indicate dosage and length of time taking

Clinical Goals

Include progress made towards these goals already (if applicable)

Specific Questions Related to this Case

Terms & Conditions(Required)

I confirm that I have obtained written consent from the patient to discuss their case within this group. I agree to take all reasonable steps to maintain patient confidentiality by excluding any identifying information, including but not limited to name and address

I Agree