What Matters [Most] To Me
We are trying to learn what patients value most from the healthcare service they receive including from their physicians.

This is an early tool that will enable patients to let their providers know “what matters most to them.” No personal information about any respondent will be made public.

Personal Information
We will not share any of your personal information.
Age *
Sex *
Ethnicity
Highest Level of Education
Occupation: (optional)
Your answer
Type of Medical Insurance
We are interested in your thoughts about the doctor-patient relationship
I know that a good relationship between my doctors and me is important to my health. Although I may not always get everything I wish for, I welcome this chance to share some of my preferences and values. Please rank the choices in order of importance to you with # 1 as the most important.
What Matters To You
When ranking your choices, please remember that # 1 is most important and the others will be ranked in descending order.
Question 1. When interacting with physicians which qualities do you value most? Please rank in order of importance. *
Ranked # 1
Ranked # 2
Ranked # 3
Ranked # 4
Ranked # 5
Ranked # 6
Ranked # 7
Kindness
Beng on time
Efforts to connect with me as a human being and not just as a patient
Fund of knowledge
Involving me in decision-making
Spending Adequate Time With Me
Explaining things fully and in the way I understand them
Comments on Questions:
Your answer
Questions # 2 My personal responsibility regarding my health is to: *
Ranked # 1
Ranked # 2
Ranked# 3
Learn as much as I can about my condition and be actively involved in decision making
Exercise, diet and lead a healthy lifestyle
Follow medical recommendations given
Comments:
Your answer
Question # 3 If lab or diagnostic tests are recommended, I would like my physician to know that: *
Ranked # 1
Ranked # 2
Ranked # 3
I only want the absolute critical tests to be performed
I want all the tests that could be helpful to understand my condition better
I want to understand how important they are before I get them done
Comments:
Your answer
Question # 4 If my doctor recommends medications: *
Ramked # 1
Ramked # 2
Ramked # 3
Ramked # 4
Ramked # 5
I want to know exactly what I am taking and why
I want the absolute minimum that I need to take for my condition
I want to take anything that can possibly help my condition
I want to understand the side effects of each medication thoroughly before accepting the prescription
I want the freedom to try alternative medicine and herbal supplements
Question # 5 In regards to my healthcare costs: *
Ramked # 1
Ramked # 2
Ramked # 3
Ramked # 4
I want to know exactly what I am being charged for
I want to know what my health insurance covers
I want to minimize my healthcare expenditure
I am willing to spend whatever I need to take care of my health
Comments:
Your answer
It will help to improve the services you receive if your health care provider knows some things about you. What would you want her or him to know? What is important to you in your life? *
Your answer
Please tell us any specific questions or comments about this form here (you can also answer "None." *
Your answer
Developers' Comments
This is a work in progress, we will modify the form as we learn more about this important area.

Thank you for taking time out to tell us what matters to you the most. We hope you have found this form useful.


Sosena Kebebe, M.D., M.P.H.
David Elpern, M.D.

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