Doctor - Patient Interaction Jordan Turner
Name (optional): 


  1. How would you rate your overall interaction with your physician?
    Very poor
    Poor
    Moderate
    Good
    Very good


  1. How often do you find yourself satisfied with the explanation your physician provides you regarding medications, conditions, etc.?
    0-20% of the time
    21-40% of the time
    41-60% of the time
    61-80 % of the time
    81-100% of the time


  1. Does your physician make you feel that your opinion and needs are valued?
    Yes
    No


  1. Have you ever felt uncomfortable to ask for further clarification on a subject from your physician?
    Yes
    No


  1. On a scale from 1 to 5, 5 being the most, how much do you feel you play an active role in deciding your best plan of care?
        1 2 3 4 5
    1  
    2  
    3  
    4  
    5  


  1. On a scale of 1 to 5, 5 being the most, how much do you feel you can openly communicate your needs and concerns with your physician?
        1 2 3 4 5
    1  
    2  
    3  
    4  
    5  


  1. What if anything would you request your doctor to consider from your perspective?


  1. Are there any thoughts you have to help strengthen the communication between you and your physician?





Mrs. Fauchier