Work with Dr. Cindy Pre-call Assessment Form

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Work With Cindy Pre-Call Assessment

Hello Physician Mom,

Please complete the form below to help streamline our upcoming conversation. It gives you a chance to ponder topics that you feel are an issue and gives me a chance to narrow my focus on how I can best help!

Please submit this form no less than 24 hours before our meeting. I look forward to speaking with you at our appointment.

Always in your corner!

Cindy Van Praag, MD, NBC-HWC
Wellness Advocate for Physician Moms

First Name

Last Name

How often do you return home from your practice mentally and/or physically exhausted?Every dayMost daysSometimesRarely

As a physician mom, what in a typical day UPLIFTS you at your practice and at home? (try to list at least 3)

As a physician mom, what in a typical day DRAINS you at your practice and at home? (try to list at least 3)

In a regular week, what do you feel you’re doing too much of? List something as a doc at work, and a mom at home with family. Feel free to add more.

What do you wish you could do more of in your practice? What about in your role as mom?

How easy is it to travel or take time off?Almost impossibleHard, but manageableSomewhat easyNot a problem

What issues, whether in your practice or with family restrict your ability to take time for yourself? (Check all that apply)

In my private practice:I don’t have much control over my work schedule.I have to share prime vacation times with my partners in the practice.I have a lot of vacation weeks, but I don’t get paid if I’m not there.I have to find my own coverage for my vacation times.I have a call schedule and have to fit the required call around my time off.I feel guilty having others cover for me at work.

Anything else?

With my home and family:My children need me constantly.My children are too small to travel.I don’t want to spend money on a sitter when I can watch the kids for free.I shoulder most of the childcare responsibilities.I shoulder most of the household responsibilities.I have to take care of my aging parents/in-laws.

Anything else?

As a busy physician mom, what area of your life exhausts you and want help to correct?

Is there anything else you would like to add before we meet?

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