CLB 3 – 4 Writing Skill Builder – Form Filling Review – Getting Things
Done
Instructions: Review your form filling skills and rules by filling out
the personal information on the form below.
Form 1
Student Registration Form
Circle one: Mr. / Mrs. /
Ms. /
Last Name: ___________________________ First
Name: __________________________
Street Address:
_______________________________________________________________
City: _____________________ Province:
____________ Postal Code: ____________
Nationality: ________________________ Place of
Birth: ________________________
Email: _______________________________ Phone
Number: ________________________
Date of Birth
(DD/MM/YYYY):
__________________ Occupation: _________________
Marital Status: _______________________ CLB Level:
__________________________
Instructor Name: ______________________ Classroom:
_________________________
Signature: ___________________________ Date:
_______________________________
Form 2
| |||
Speaking - Guided Task: Dental Clinic Reception Intake (Sharing Information)
Instructions: Student B is at
the dental clinic reception desk complaining of a problem. Student A is the
receptionist completing a patient intake record.
Role Cards
+-----------------------------------------------------------------------+
| ROLE CARD A:
RECEPTIONIST |
+-----------------------------------------------------------------------+
|
You work at the dental clinic. Welcome the patient and complete |
|
the intake form below by asking questions. |
|
|
|
Patient Name: _________________________________________________ |
|
Main Complaint: _______________________________________________ |
|
Onset (When started): _________________________________________ |
|
Triggers (When it hurts): ______________________________________ |
|
Brushing / Flossing Frequency: ________________________________ |
|
Last Check-up: ________________________________________________ |
+-----------------------------------------------------------------------+
+-----------------------------------------------------------------------+
| ROLE CARD B:
PATIENT |
+-----------------------------------------------------------------------+
|
You are visiting the dental clinic. Use your details below to answer |
|
the receptionist's questions clearly. |
|
|
|
• Problem: Severe pain in lower right molar |
|
• Onset: Started 4 days ago |
|
• Trigger: Pain increases when drinking hot tea or chewing food |
|
• Habits: Brush once a day, floss rarely, drink soda 2x a week |
|
• Last Check-up: Over 2 years ago |
+-----------------------------------------------------------------------+
