Brief Patient Feedback Form We would like your honest feedback. Please answer these questions either yes or no about the visit you had today. Think about a specific provider or staff member for example, your doctor, – nurse, medical assistant when answering. – Did this provider or staff member explain things in a way that was easy to Yes No understand? Did this provider or staff member use medical words you did not Yes No understand? Was this provider or staff member warm and friendly? Yes No Did this provider or staff member listen carefully to you? Yes No Did this provider or staff member encourage you to ask questions? Yes No Did this provider or staff member answer all your questions to your Yes No satisfaction? Did you see this provider or staff member for a specific illness or for any Yes No health condition? If No, Form Is Complete If Yes, Yes No 7a. Did this provider or staff member give you instructions about what to do to take care of this illness or health condition? If No, Form Is Complete If Yes, Yes No 7b. Were these instructions easy to understand? 7c. Did this provider or staff member ask you to describe how you were Yes No going to follow these instructions?
Brief Patient Feedback Form We would like your honest feedback. Please answer these questions either yes or no about the visit you had today. Think about a specific provider or staff member – for example, your doctor, nurse, medical assistant – when answering. Did this provider or staff member explain things in a way that was easy to understand? Yes No Did this provider or staff member use medical words you did not understand? Yes No Was this provider or staff member warm and friendly? Yes No Did this provider or staff member listen carefully to you? Yes No Did this provider or staff member encourage you to ask questions? Yes No Did this provider or staff member answer all your questions to your satisfaction? Yes No Did you see this provider or staff member for a specific illness or for any health condition? Yes No If No, Form Is Complete If Yes, 7a. Did this provider or staff member give you instructions about what to do to take care of this illness or health condition? Yes No If No, Form Is Complete If Yes, 7b. Were these instructions easy to understand? Yes No 7c. Did this provider or staff member ask you to describe how you were going to follow these instructions? Yes No
healthlittoolkit2-tool4d.docx