Patient and Family Member S Evaluation of Geropsychiatry Fellow

PATIENT AND FAMILY MEMBER’S EVALUATION OF

GEROPSYCHIATRY FELLOW

Name of Doctor:______

Date:______Place:______

In order to help our fellows improve, we ask you to take a few minutes to complete this form. Please do not sign your name or identify yourself.

Please mark the number that most closely corresponds to your opinion: Strongly Disagree Not Agree Strongly N/A

Disagree Sure Agree

1. The doctor cared for me in a way that made me feel at ease 1 2 3 4 5 N/A

2. The doctor showed an interest in my problems 1 2 3 4 5 N/A

3. The doctor asked good questions that helped me explain my problems 1 2 3 4 5 N/A

4. The doctor listened carefully 1 2 3 4 5 N/A

5. The doctor explained what he/she found so I could understand 1 2 3 4 5 N/A

6. The doctor discussed my choices for treatment 1 2 3 4 5 N/A

7. The doctor answered my questions 1 2 3 4 5 N/A

8. The doctor worked with my family and other people who are helping me 1 2 3 4 5 N/A

9. The doctor told me about ways of getting help in my community 1 2 3 4 5 N/A

10. The doctor treated me as an equal person 1 2 3 4 5 N/A

11. The doctor received my consent or permission before doing tests or 1 2 3 4 5 N/A talking about me with other doctors and health professionals

12. The doctor respects cultural, ethnic, racial, and language differences 1 2 3 4 5 N/A

Please tell us anything else about your doctor that you think is important:

______

Thank you for your time and for your help.

FOR ADMIN USE ONLY:

Patient Care (1-3); Interpersonal & Communication (4-7); Systems-Based Practice (8-9); Professionalism (10-12)

AAGP gratefully acknowledges that this form was used with permission from

David Roane, MD, Associate Professor of Clinical Psychiatry,

Albert Einstein College of Medicine