University of New Mexico

Department of Dermatology

RESIDENT_______________________________________ DATE_______________

Parent Questionnaire

Including information on the dermatology residents’ relationships with the people who they treat

is an important part of their job. Please fill out this form on how well your child’s physician works

with you. Thank you.

How many times have you seen this physician? ______________________________________________

How well do you know this physician? □ not at all □ not well □ somewhat □ well □ very well

Compared to other physicians, I know this one:	Unsatisfactory	Needs Improvement	Satisfactory	Above Average	Exceptional
Is polite to me
Spent enough time with me and my child
Listened to me
Asked for my ideas
Showed interest in me and my child
Clearly explained his/her ideas about my child’s problems
Gave clear and useful ideas about what I should do about my child’s problems
Cares about my child
Answered my questions

Comments (please provide):

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Please return form to front desk. Thank you.

University of New Mexico

Department of Dermatology

RESIDENT_______________________________________ DATE_______________

Patient Questionnaire

Including information on the dermatology residents’ relationships with the people who they treat

is an important part of their job. Please fill out this form on how well your physician works with

you. Thank you.

How many times have you seen this physician? ______________________________________________

How well do you know this physician? □ not at all □ not well □ somewhat □ well □ very well

Compared to other physicians, I know this one:	Unsatisfactory	Needs Improvement	Satisfactory	Above Average	Exceptional
Is polite to me
Spent enough time with me
Listened to me
Showed interest in me
Clearly explained his/her ideas about my problems
Gave clear and useful ideas about what I should do
Cares about my condition
Answered my questions

Comments (please provide):

Please return form to front desk. Thank you.

University of New Mexico

Department of Dermatology

RESIDENT_______________________________________ DATE_______________

POSITION (Optional)_______________________________

Co-Worker Questionnaire

Including information on the dermatology residents’ relationships with non-physician co-workers

is an essential part of their performance review. Please complete this form based on your

experiences working with this resident physician. Thank you.

How well do you know this physician? □ not at all □ not well □ somewhat □ well □ very well

Compared to other physicians, I know this one:	Unsatisfactory please explain below	Needs Improvement please explain below	Satisfactory	Above Average	Exceptional
Communicates effectively with co-workers
Is courteous to co-workers
Respects the knowledge/skills of co-workers
Collaborates well with co-workers
Sees patients on time
Is courteous to patients & families
Communicates effectively with patients
Acts non-judgmentally with patients/families
Completes paperwork in a timely manner

Comments (please include explanation of any ratings of Unsatisfactory and/or Needs Improvement):

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