Gender: Male Female
Age:
Race: Caucasian Hispanic Black Asian Other
Family Status: Single Married Widowed Divorced
How Many Children Where do your children live?
Highest Level of Education:
Did not graduate HS High School graduate 2 year degree 4 year degree graduate degree doctorate
Your profession: Annual Household Income: under $35K $35K to $80K $80K to $100K $100K to $250K $250K or more
Hobbies and Interests
Media They Consume
Where do you get most of your medical information?
Political Affiliation Religious Affiliation What 3 things do you value most in life right now?
What motivtes you to persevere when something is difficult?
What are your biggest 3 fears right now?
Are you convinced that something is true more by stories or statistics or both equally ?
When you go to the doctor’s office, what 3 things do you appreciate the most about your visit?
When you go to the doctor’s office, what 3 things irritate or bother you the most?
As a person with (diagnosis), what is your single greatest question regarding your diagnosis?
What is your greatest challenge regarding your diagnosis that you experience on a daily basis?
If I were following you around for a day, how would I know, what would I see or hear that would
If you could wave a magic wand and have the ideal experience from your doctor and his/her staff in dealing with this struggle, what would that experience look, feel and sound like for you?
Pre-Appointment
During Appt
Post Appt
What have you never seen a doctor do that you wish your doctor would do?
What do you already do on your own, outside of your doctor’s office, to take care of your health? (Check any / all that apply)
Exercise for Minutes days per week at low medium high intensity
Eat a healthy Diet : Vegan Vegetarian Raw Food Macrobiotic Low Carb Paleo Mixedor Other:
Sleep hours per night Drink glasses water per day Get minutes or hours sunlight per dayAvoid: alcohol tobacco recreational drugs caffiene sugar high fat / deep fried
Take Classes / Research / Read about health Time with friends and family: Days per week Time to meditate / pray: Days per week Time to pursue hobbies and interests: Days per week Is there any way your doctor could make your experience with your diagnosis more interesting?
Is there any way your doctor could make your experience with your diagnosis more interesting?
On a scale of I -10 ( I meaning, “/f it goes on like this forever, even though I don’t like it, I can live with
it”, and 10 meaning, “This is causing so much distress / worry / pain that ] have to resolve this NOW and I will do
anything and spend any amount of money to have it resolved”), how important is it to you to resolve
this health concern you have?
1 2 3 4 5 6 7 8 9 10
What could your doctor do to create a more meaningful relationship with you?
What could your doctor do that would make your treatment less generic and more specific to your personal needs?
What do you want most from your doctor?
How much time do you think that would take?
What do you want most from your doctor’s staff?
How much time do you think that would take?
How would you like to hear from your doctor or his staff in between visits?
Is there any other advice you’d like to give us to understand how to best serve you?
