Patient Feedback Form
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1
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3History 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.
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