Patient Questionnaire 

The following questions will help us with our evaluation process. If you do not feel that you have enough information to answer a question, leave it blank. Thank you for your assistance. Your responses will be confidential.

Physician _________________________

My doctor spends enough time listening to my symptoms and concerns?

(Patient care, communication, professionalism)

Strongly agree          Agree            Neutral             Disagree            Strongly disagree

My doctor seems familiar with my problem and seems to know what tests and treatments will be appropriate. (Medical knowledge, patient care)                   

 Strongly agree          Agree            Neutral             Disagree            Strongly disagree

My doctor listens to me and my family and is able to communicate effectively with us. (Interpersonal and communication skills)

Strongly agree          Agree            Neutral             Disagree            Strongly disagree

My doctor acts professionally with high ethical and moral standards and respects my confidentiality. (Professionalism)

Strongly agree          Agree            Neutral             Disagree            Strongly disagree

My doctor seems familiar with the UNM /VAMC healthcare system and my resources and insurance and is willing and able to help me understand the costs and risks of tests and treatments. (SBL)

Strongly agree          Agree            Neutral             Disagree            Strongly disagree