Evaluation
12/30/2003
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Please fill out this questionnaire so we may help the medical resident or student you (or your family member) saw today or over the past few days know how she/he did. Your evaluation will help the individual learn how to improve his/her communication with patients. All comments and ratings are anonymous; the doctor/student will not know who filled out this form. You are encouraged to write comments.
THE DOCTOR: Select Resident... Alex Jones Any Resident Demo Resident Jon Smith Mike Crouch
Can't Tell
Yes
No
1.
Introduced him/herself to me
2.
Introduced other members of the health care team to me if they were in the room with us
3.
Respected my privacy
4.
Is available when I need him/her or there is someone to take his/her place
5.
Spoke to me and/or other members of my family so we could understand what was going on
6.
Asked questions in a way that let me tell my concerns and feelings
7.
I felt like the doctor listened to me
8.
I felt like the doctor took enough time with me
9.
I felt like the doctor was interested in my problems and concerns
10.
He/she gave me instructions on how to treat my problem by either telling me or giving me something in writing
Comments:
Please provide comments about any statements to which you answered “no”.