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Health Literacy Universal Precautions Toolkit, 2nd Edition

Brief Patient Feedback Form

Table of Contents

[Microsoft Word - 20.78 KB]

We would like your honest feedback. Please answer these questions either yes or no about the visit you had today. Think about a specific provider or staff member—for example, your doctor, nurse, medical assistant—when answering.

1. Did this clinician or staff member explain things in a way that was easy to understand?	Yes	No
2. Did this clinician or staff member use medical words you did not understand?	Yes	No
3. Was this clinician or staff member warm and friendly?	Yes	No
4. Did this clinician or staff member listen carefully to you?	Yes	No
5. Did this clinician or staff member encourage you to ask questions?	Yes	No
6. Did this clinician or staff member answer all your questions to your satisfaction?	Yes	No
7. Did you see this clinician or staff member for a specific illness or for any health condition?	Yes	No
If No, Form Is Complete
a. Did this clinician or staff member give you instructions about what to do to take care of this illness or health condition?	Yes	No
If No, Form Is Complete
b. Were these instructions easy to understand?	Yes	No
c. Did this clinician or staff member ask you to describe how you were going to follow these instructions?	Yes	No

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Page last reviewed September 2020

Page originally created February 2015

Internet Citation: Brief Patient Feedback Form. Content last reviewed September 2020. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/health-literacy/improve/precautions/tool4d.html