For each item, circle the number corresponding to your opinion. | Completely Disagree | Somewhat Disagree | Somewhat Agree | Completely Agree | |
---|---|---|---|---|---|
1 | Asks patient to describe how his/her health problems are affecting his/her daily life | 1 | 2 | 3 | 4 |
2 | Asks patient to give his/her perception of his/her symptoms | 1 | 2 | 3 | 4 |
3 | Asks patient to express his/her concerns about his/her symptoms | 1 | 2 | 3 | 4 |
4 | Asks patient for his/her expectations of the visit | 1 | 2 | 3 | 4 |
5 | Takes the patient’s opinion and concerns into account throughout the interview | 1 | 2 | 3 | 4 |
6 | Gives patient time to express himself/herself, and when it is necessary to interrupt the patient, does so in a tactful manner. | 1 | 2 | 3 | 4 |
7 | Uses open-ended and closed-ended questions appropriately | 1 | 2 | 3 | 4 |
8 | Responds appropriately to patient’s non-verbal communication | 1 | 2 | 3 | 4 |
9 | Avoids being aloof and abrupt with patient | 1 | 2 | 3 | 4 |
10 | Respects patient’s opinions | 1 | 2 | 3 | 4 |
11 | Looks at patient when speaking to patient and when patient is speaking | 1 | 2 | 3 | 4 |
12 | Expresses himself/herself clearly and precisely | 1 | 2 | 3 | 4 |
13 | Explains the proposed course of action | 1 | 2 | 3 | 4 |
14 | Avoids medical jargon | 1 | 2 | 3 | 4 |
15 | Checks throughout the interview to ensure that the patient understands | 1 | 2 | 3 | 4 |