Medical Evaluation Clarity Assessment
Please complete this form to help us assess and improve the clarity of medical evaluations provided.
Evaluator's Full Name
*
First Name
Last Name
Evaluator's Role
*
Please Select
Physician
Nurse
Specialist
Patient
Caregiver
Other
Patient's Full Name
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Medical Evaluation
*
Please Select
Initial Consultation
Follow-up Visit
Diagnostic Assessment
Treatment Planning
Discharge Summary
Other
How clear was the explanation of the diagnosis?
*
1
2
3
4
5
Please rate the following aspects of the medical evaluation clarity:
*
Rows
Very Unclear
Unclear
Neutral
Clear
Very Clear
Explanation of condition
1
2
3
4
5
Details of treatment plan
6
7
8
9
10
Risks and benefits discussed
11
12
13
14
15
Next steps and follow-up
16
17
18
19
20
Opportunity to ask questions
21
22
23
24
25
Were you provided with written materials or resources?
*
Yes
No
How confident do you feel in understanding the medical information provided?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
What could have improved the clarity of your medical evaluation?
Do you have any additional comments or suggestions regarding the clarity of the evaluation?
Submit Assessment
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