Form 1 Card survey (patient)

1. Patient Card Survey

Demographics

1. Time of day: _____________________

2. What is your age?

____ years old

3. What is your gender?

____ Female

____ Male

____ Transgender

____ Other

4. What is the highest level of education you have completed?

____Some high school or less

____High school graduate or GED

____Some college or associate’s degree (including community college) or vocational/technical training

____4-year college graduate (bachelor’s degree)

____Graduate or professional school degree

____Other, please specify:

Other education: ________

5. Are you of Hispanic, Latinx, or Spanish origin?

____Yes

____No

____Prefer not to answer

6. What is your race? Please mark all that apply.

____White

____Black or African-American

____Asian

____Native Hawaiian or other Pacific Islander

____American Indian or Alaskan Native

____Other, please specify:

____Prefer not to answer

Purpose of Visit

Briefly, what was the main problem or health concern that brought you to the clinic today?

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Control Preference Scale

Decisions about how to treat your health problems can be made in many different ways. We would like to learn more about how you plan to make this decision. Please choose the ONE statement that best applies.

1. I prefer to make the decision about which treatment I will receive.

2. I prefer to make the final decision about my treatment after seriously considering my doctor’s opinion.

3. I prefer that my doctor and I share responsibility for deciding which treatment is best for me.

4. I prefer that my doctor makes the final decision about which treatment will be used, but seriously considers my opinion.

5. I prefer to leave all decisions regarding treatment to my doctor.

Medical maximizing-minimizing scale

Sometimes medical action is clearly necessary, and sometimes it is clearly not necessary. Other times, reasonable people differ in their beliefs about whether medical action is needed. In situations where it’s not clear, do you tend toward taking action or do you tend toward waiting and seeing if action is needed?

I strongly lean toward waiting and seeing 1

2

3

4

5

I strongly lean toward taking action 6

Satisfaction with discussion

Thinking back to the conversation you just had with your doctor, how satisfied are you with the discussion?

Not at all satisfied 1

2

3

4

Extremely satisfied 5

Identification of a decision or problem solving

 

 In your visit today, did any of the following occur? (circle Yes or No)

1. I had a choice between two or more treatment options: Yes / No

2. Problem-solving was needed between me and my doctor to determine the best care plan: Yes / No

If you answered “no” to both statements, you are finished with this survey.

If you answered “yes”, please answer the last set of questions below.

OPTIONS scale

	Strongly agree 1	Agree 2	Disagree 3	Strongly disagree 4
A health problem was identified and it was made clear that a decision was needed
My clinician respected my preference to take part (or not) in the decision.
My clinician discussed different options (including the possibility of doing nothing) with me.
My clinician discussed advantages, disadvantages and possible outcomes of options with me.
My clinician made sure that I understood the information we discussed.
My clinician described to me more than one way to manage the health problem.
My clinician and I discussed ideas or expectations about managing the health problem.
My clinician offered different sources of information (e.g., leaflets, websites, contact with other people) to help make the decision.
My clinician asked if I had questions.
My clinician asked me about my preferences.
My clinician and I discussed my concerns or worries about managing the health problem.
A decision was made; Or, my clinician and I agreed to postpone making a decision
My clinician and I discussed the possibility of coming back to the decision.