pATl, E NT sATt s F Acit o t t u E srt N

e o N A, R E

Evaluation of Physicia ns
The following are comments patients sometimes say about their doctors and the medical care they receive. .please
think about Doctor whom youjust saw, and rate how you agree or disagree with each
statement by checking one of the boxes on each line. PLEASE READ EACH STATEMENT CAREFULLY. Ajter
several months, your opinions will be combined with many others and given to the doctor in the form of a rummary.
Please be assured that your name will not be used, unless you so specify. We think that the information you provide wiil
be very valuable to us in our continuing efforts to improve the care provided to our patients. Please .ornplet" and return
this form BEFORE you leave. Thank you for your time and eooperation.

Flease check (V) best dercription

1. This doctor treated me in a

friendly manner
2. I hrlr,re some doubts about the
ability ofthis doctor
3. This doctor seemed cold and
impersonal
4. This doctor:.did his/her best to
keep me from worrying
5. Thisdoctor examined me as
carefully as was necessary
6. This doctor should have treated
nre with more respeit

7. I have some doubts about the

treatment suggested by this
dc.:.nr
8. This doctor seemed very'
comp€tent and well-lrained
9. This doctor seemed to have a
genuine interest in me as a
person
"
10. Tht,r doctor left me with many
unanswered questions about
my condition nnd its treatment
11. Thiri doctor used words that I
did not understand
12. I have a great deal ofconJidence
in this doctor
f 3. I felt I could tell thisdocior
about very personal problems
14. I did not feel free to ask this
doctor questiohs
15. Thisdoctor should have spent
m'l"e time talking to me