Patient Feedback Form

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History and Physical Diagnosis
Videotaped Interviews
M2 Class, Page 1 of 3
Student:
Patient Initials:
Date:
PATIENT FEEDBACK FORM
Instructions:
Below are some questions about your interview. Please consider each question and circle the
number on the continuum line that best represents your feelings toward that question. Your
responses will be helpful to the medical students for improving their medical interviewing skills.
Please feel free to add comments for any question. Thank you very much for your cooperation.
1.
Were you comfortable during the interview?
1
2
3
4
5
Not very
Somewhat
Very
comfortable
comfortable
comfortable
2.
Were the student’s appearance and behavior professional?
1
2
3
4
5
Not very
Somewhat
Very
professional
professional
professional
3.
Did the student begin by asking an open-ended question about your complaint?
1
2
3
4
5
Not very
Somewhat
Very
open-ended
open-ended
open-ended
4.
Did the student listen to you during the interview?
1
2
3
4
5
Did not
Listened
Listened
listen well
somewhat
very well
5.
Was the student sincerely concerned about your complaint or problem?
1
2
3
4
5
Not very
Somewhat
Very
concerned
concerned
concerned
6.
Were the questions and statements made by the student appropriate and timely?
1
2
3
4
5
Not very
Somewhat
Very
appropriate
appropriate
appropriate
SP-Feedback-Hx.doc
rev 1/14/06
Continues on the next page.
History and Physical Diagnosis
Videotaped Interviews
M2 Class, Page 1 of 3
Student:
Patient Initials:
Date:
PATIENT FEEDBACK FORM
Instructions:
Below are some questions about your interview. Please consider each question and circle the
number on the continuum line that best represents your feelings toward that question. Your
responses will be helpful to the medical students for improving their medical interviewing skills.
Please feel free to add comments for any question. Thank you very much for your cooperation.
1.
Were you comfortable during the interview?
1
2
3
4
5
Not very
Somewhat
Very
comfortable
comfortable
comfortable
2.
Were the student’s appearance and behavior professional?
1
2
3
4
5
Not very
Somewhat
Very
professional
professional
professional
3.
Did the student begin by asking an open-ended question about your complaint?
1
2
3
4
5
Not very
Somewhat
Very
open-ended
open-ended
open-ended
4.
Did the student listen to you during the interview?
1
2
3
4
5
Did not
Listened
Listened
listen well
somewhat
very well
5.
Was the student sincerely concerned about your complaint or problem?
1
2
3
4
5
Not very
Somewhat
Very
concerned
concerned
concerned
6.
Were the questions and statements made by the student appropriate and timely?
1
2
3
4
5
Not very
Somewhat
Very
appropriate
appropriate
appropriate
SP-Feedback-Hx.doc
rev 1/14/06
Continues on the next page.
History and Physical Diagnosis
Videotaped Interviews
M2 Class, Page 2 of 3
7.
Did the student use language and words that you could understand?
1
2
3
4
5
Used words
Usually used
Almost always
that I did not
words that I
used words that
understand
understood
I understood
8.
Did the student allow you to talk about the concerns you wanted to talk about?
1
2
3
4
5
No, I did not
I somewhat
Yes, I very
discuss my
discussed
much discussed
concerns
my concerns
my concerns
9.
Did you have additional information you thought was important, but the student did not
ask about?
1
2
3
4
5
I had no
I had some
I had lots of
additional
additional
additional
information
information
information
10.
Were you distracted by the student (fidgeting, paper moving, hand motions, poor eye
contact, etc.)?
1
2
3
4
5
Not distracted
Somewhat
Very
at all
distracted
distracted
If distracted, what specifically did the student do?
11.
During the interview, did you feel you could ask questions or make comments at any
time?
1
2
3
4
5
Not able to
Somewhat able
Very free to
ask questions
to ask questions
ask questions
at all
12.
Did you feel that the interview and its content were to be confidential?
1
2
3
4
5
Not sure if
Somewhat
Very
confidential
confidential
confidential
Continues on the next page.
History and Physical Diagnosis
Videotaped Interviews
M2 Class, Page 3 of 3
13.
At the end, did the student summarize the major points of the entire interview?
1
2
3
4
5
Did not
Summarized
Summarized
summarize
somewhat
very well
14.
Would you feel comfortable returning to this student for medical care in the future?
1
2
3
4
5
No,
Possibly,
Definitely
definitely not
I’d think about it
15.
What specific suggestions/comments do you have regarding the interview or student?
We appreciate your taking time to complete this form.

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