|
| No. | Items | SA | A | NAD | D | SD |
| 5 | 4 | 3 | 2 | 1 |
|
| 1 | Your doctor greeted you in a way that made you feel comfortable | | | | | |
| 2 | Discussed your reason(s) for coming today | | | | | |
| 3 | Encouraged you to express your thoughts concerning your health problems | | | | | |
| 4 | Listened carefully to what you had to say | | | | | |
| 5 | Understood what you had to say | | | | | |
| 6 | If a physical examination was required for your health concerns, the doctor fully explained what was done and why | | | | | |
| 7 | Explained the lab tests needed (e.g., blood, X-rays, ultrasound, etc.) | | | | | |
| 8 | Discussed treatment options with you | | | | | |
| 9 | Gave you as much information as you wanted | | | | | |
| 10 | Checked to see if the treatment plan(s) was acceptable to you | | | | | |
| 11 | Explained medications, if any, including possible side effects | | | | | |
| 12 | Encouraged you to ask questions | | | | | |
| 13 | Responded to your questions and concerns | | | | | |
| 14 | Showed concern about you as a person | | | | | |
| 15 | Involved you in decisions about your health as much as you wanted | | | | | |
| 16 | Discussed next steps including any follow-up plans | | | | | |
| 17 | Checked to be sure you understood everything | | | | | |
| 18 | Spent the right amount of time with you | | | | | |
| 19 | Overall, you were satisfied with your visit to the doctor today | | | | | |
|
