CyberPatient Case- Creation Request Form

As part of our initiative to support collaboration, CyberPatient values working with our partners to expand the case library. By constantly growing our case library, we will represent local pathologies taught in your unique curriculum and give your students the opportunity to learn from diagnoses across the globe.

Part 1: Institution Information & Case Creation Team

First name*

Last name*

Email*

Institution name*

Your position and department*

Are you the Case Development Leader? (if yes, skip the next 4 questions)*

Please share some information about your Case Development Team.

Case Development Leader- First name

Case Development Leader- Last name

Case Development Leader- Email

Case Development Leader- Position and department

Case Development Team (names, credentials and emails of other team members)*

Part 2: Case Information

Diagnosis*

Learning objectives*

Patient name and age*

Important questions for history taking*

Important exams for physical examination*

Provisional diagnosis (list three additional diagnoses to differentiate)*

List of diagnostic investigations (digital assets will be requested later)*

Management and treatment plan (include hospital days if required)*

Recommendations (e.g. "elevate the head of the bed")*

Follow-up (primary care provider/ phone call/ no follow-up visit and when)*

Please cite your references*

Part 3: Local Authority Approval

Please attach written approval for the Case Creation project from your local authority*

Following this request, CyberPatient's Expert Medical Committee will confirm approval of the case. With approval, the next steps will include:

Introduction to the collaborative team from CyberPatient
Request for diagnostic and treatment assets
Creation of the alpha version and review
Creation of the beta version and peer-review process
Publication

I understand that once the case is published, the assets and contents become the property of Interactive Health International Ltd. The case will be public to all institutional partners and users of CyberPatient.*