Patient Questionnaire

1. Name: ______________________________________ Date of Birth: _________________

2. How do you wish to be addressed by nurses and physicians:

a. by your first name
b. by Mr., Mrs. or Ms.
c. other: ___________________________

3. Do you prefer that doctors, nurses, etc.:

a. make physical contact with you (such as placing a hand on your arm, holding your hand, etc.)
b. respect your "space"?

4. Do you prefer that your doctors/nurses act:

a. casual, playful and/or informal with you
b. professional and businesslike.

5. When getting explanations/instructions from your physician, would you prefer:

a. general explanations
b. detailed explanations?

6. Do you prefer that explanations/instructions be:

a. verbal
b. written
c. both

7. When receiving results/diagnoses from your physician, would you prefer:

a. guarded, gently-delivered information
b. straight-forward, no holds-barred delivery of information

8. When prescribing medication, do you want the doctor to:

a. discuss fully the dosing, possible interactions, and side effects
b. allow you to talk with the pharmacist about that

9. How personal do you want your physician interaction to be?

a. very involved, very personal -- I want the physician to call to check on me when I've been sick, remember who I am from visit to visit, and remember what illnesses I have and what medications I take
b. somewhat involved -- I want the physician to know what illnesses I have and what medications I take
c. I just want my physician to treat/cure my illnesses and prescribe what medications I need in order to get well

10. Do you prefer that your doctors/nurses:

a. acknowledge and apply spirituality to their dealings with you
b. keep spirituality private

11. Do you wish your doctor/nurse to:

a. question you about and discuss sexual issues or problems
b. not address sexuality issues or problems at all

12. Do you wish your doctor to:

a. address living-will or end-of-life issues with you
b. not discuss those issues