Family Medicine Field Specific Advisor

Name

First Last

Email

Expected year of graduation

(i.e., Class of ______)

Where are you from originally?

Please indicate your degree of certainty that you will apply in Family Medicine

(from 0% to 100%)

If you are sure you are going into FM, at what point did you decide that?

Before medical school
1st year
2nd year
3rd year
4th year
I have not decided yet

Were you in FaMeS/AMP?

Yes
No

In what year of medical school did you enroll in FaMeS/AMP?

Did you do the Summer Externship?

Yes
No

Are you planning to concurrently apply in any other specialty?

Yes
No

If you will take longer than 4 years to graduate, please indicate the reason here:

What part or parts of the country are you interested in for residency (if you know)?

Are you planning any away electives during 4th year?

Yes
No

If you are planning any away electives during 4th year please indicate where:

Please indicate if you have had any academic difficulties (failed boards, had to repeat courses or clerkship, or required extra time to complete graduation requirements):

(This helps us plan better how to counsel you.)

Have you already spoken with a FM faculty about being your FSA?

Yes
No

If you have spoken with a FM faculty about being your FSA, please indicate who:

Do you have a request for a specific FM faculty?

Yes
No

If you have a request for a specific FM faculty, please indicate below:

(We will do our best to accommodate requests, but cannot guarantee all will be met. You are also encouraged and allowed to meet with FM faculty who are not your FSA)

Is there anything else you would like to let us know at this point?