Assessment Questionaires

Our surveys served as a tool for identifying and prioritizing areas in which patient-centered care, coordination, communication, and quality could be improved.

Interpersonal Care Team Survey

1. What is your current job tile/ position?

· Nurse

· Pharmacist

· Nutritionist/ Dietician

· Physical Therapist / Occupational Therapist

· Case Manger

· Nurse Practitioner

· Doctor

· Physicians Assistance (PA)

2. Years of experience:

· Less than 1

· 1-5 years

· 6-10

· More than 10

· More than 20

3. How often do you provide your patients with educational material?

Always/Often/ Sometimes/Never

4. Do you feel the patient education you provide to your patients is effective?

Always/Often/Sometimes/ Never

5. What form of patient education do you use most often?

· Face to Face/ Verbal discussion

· Pamphlets/ Printed Sheets

· Videos

· Educational Apps

· OTHER:

6. Do you feel the patient education material provided meets the needs of your patient population?

Always/ Often/ Sometimes/ Never

7. How often do you evaluate the effectiveness of your patient education?

Always/ Often/ Sometimes/ Never

8. Do interdisciplinary team members effectively exchange information with one another about their patients?

YES / NO

9. How do you communicate with members of the interdisciplinary care team?

· Phone

· Email

· In person

· OTHER:

10. How often do members of the interdisciplinary team communicate to discuss patient needs?

Always/ Often/ Sometimes/ Never

11. What would you do to improve patient education among your patient population:

Patient Survey Questionnaire

Please Fill in or Circle the Answer below the best you can.

How older are you?

MALE

FEMALE

Are you: Single Married Widowed Divorced

DO you live Alone? YES / NO

Do you Have a support system? YES / NO

Do you feel Safe at home? YES / NO

What is your highest level of Education? Elementary High school/ GED College More than College

Do you speak English? YES /NO

If YES, how well do you speak English? NOT WELL GOOD VERY GOOD EXCELLENT

In What Ways Do You Learn Best? Written Material Visual Aids Discussion Active Listening

How Do you Learn about your Health? TV Internet Magazines Other

Do you have any religious or cultural beliefs that may impact your treatment? YES / NO

Can you walk up a flight of stairs? YES/ NO

Can you walk more than 1 block without stopping? YES/NO

How did you get here today? Personal Car Public Transportation Car Service Other:

What are your Health Concerns?

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