Patient Decisional Balance Sheet

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DECISIONAL BALANCE SHEET
Patient name ______________________________
Date completed __________
What are the benefits of going into the
What are the disadvantages of going
hospital?
into the hospital?
Importance Rating Scale
On a scale of 1 to 10, with 1 meaning not important and 10 meaning
very important, how important is it to you to stay out of the
hospital?_________
Why not a____? (choose a rating 2 numbers lower and record the
patient’s response)_____________________________________________

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