ࡱ> GKF% bjbjSS 4:1xAd1xAd &&&&&::::V:=$^&&& &&TpNlu  0=(,33T3&TT=3 : PATIENT ASSESSMENT OF DOCTOR Doctors Name: Department: Date: The residents in the [Department] value their patients and want to provide them with quality health care. Please take a few minutes to let us know how your doctor treated you during your visit. For each of the sentences listed below, rate on a scale of 0 to 10 your level of agreement with each statement; with 5 indicating moderate agreement, 0 indicating no agreement (disagree) and 10 indicating complete agreement (strongly agree). You may also use NA (not applicable) for any item that does not pertain to you. We have also included space for commenting about your visit. Please feel free to let us know any details of your visit that would provide us with a clearer understanding of your experience. If you have any questions about this survey, please contact [Name and Phone#]. Once you have completed the form, please leave it with the nurse at the end of your appointment today. Thank you for your help. My doctor greeted me in a way that made me feel at ease (comfortable). Comment:  My doctor showed interest in me as a person. Comment: My doctor demonstrated sensitivity to issues that are important to me, including my culture, religion, age, gender, and disabilities. Comment:  My doctor treated me with respect and compassion. Comment:  My doctor treated me in an appropriate, professional and ethical manner. Comment:  My doctor gave me enough time to explain my problem completely. Comment:  My doctor described what to expect from treatments, tests or other procedures that were going to happen. Comment:  My doctor explained my problem (illness) so that I could understand it. Comment:  My doctor gave me a chance to ask questions without interrupting. Comment:  My doctor gave me a chance to express my feelings or ideas and participate in planning my treatment. Comment:  My doctor was able to diagnose my medical problem and to treat it effectively. Comment:  My doctor respected my confidentiality and did not discuss my medical care with others without my permission. Comment:  My doctor communicated and participated with other health care providers to plan and carryout my treatment. Comment:  My doctor helped me to coordinate with other healthcare systems and followed-up on my treatment progress. Comment:  I feel satisfied with the care I received from my doctor. Comment: Is there anything else youd like us to know about your doctor or [Clinic]? Thank you for your help! +./9;<=ADEZgB C T W ôôôӊ~nanL7(h7!h7!5B*CJOJQJaJph(h7!h>5B*CJOJQJaJphh9S5CJOJQJaJh7!h>5CJOJQJaJh9SCJOJQJaJhQVh>CJOJQJaJhU$h9SCJ OJQJaJ h>CJOJQJaJhU$h>CJOJQJaJhU$h>5CJOJQJaJhU$h>CJ OJQJaJ h7!h>5Cϴ7!5Cϴ./<=DE H I Tkd$$If0V%V" t%644 ayt & F$Ifgd $Ifgdgd>gd>$a$gd7! 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