Patient Perceptions and Satisfaction
This questionnaire is designed to understand your practitioner's nonverbal behavior, as well as your satisfaction with him or her. Please answer based on your most recent visit to a physician, dentist, optometrist, nurse practitioner, or any other medical professional licensed to diagnose and treat.

These responses are anonymous, voluntary and confidential. You do not have to fill out any questions you do not wish to and are free to stop taking the survey at any time. Thank you for your participation!
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Participant Demographic Information
Please indicate the appropriate response.
Your sex:
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Age:
Ethnicity
Title or sub-specialty of medical professional seen (i.e. family medicine physician, dermatologist, nurse practitioner, etc.)
Sex of Practitioner:
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Are you a new or established patient with this practitioner?
Select new only if this was your first visit.
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Recency
Number of days since visit occurred:
Nonverbal Observer Report
DIRECTIONS: The following statements describe ways some people behave while talking with or to others. Please indicate in the space at the left of each item the degree to which you believe the statement applies to your practitioner. Please use the following 5-point scale:

1 = Never; 2 = Rarely; 3 = Occasionally; 4 = Often; 5 = Very Often

Using the scale provided, simply select the number/value that most closely represents your opinion.  You are encouraged to use the “Comments” line to expand on or clarify your responses. Some questions will seem redundant; simply do your best to answer to the best of your recollection.
1.          He/she uses her/his hands and arms to gesture while talking to people.
Rarely
Very Often
Clear selection
2.        He/she touches others on the shoulder or arm while talking to them.
Rarely
Very Often
Clear selection
3. He/she uses a monotone or dull voice while talking to people.
Rarely
Very Often
Clear selection
4. He/she looks over or away from others while talking to them.
Rarely
Very Often
Clear selection
5. He/she moves away from others when they touch her/him while they are talking.
Rarely
Very Often
Clear selection
6.  He/she has a relaxed body position when he/she talks to people.
Rarely
Very Often
Clear selection
7. He/she frowns while talking to people.
Rarely
Very Often
Clear selection
8. He/she avoids eye contact while talking to people.
Rarely
Very Often
Clear selection
9. He/she has a tense body position while talking to people.
Rarely
Very Often
Clear selection
10. He/she sits or stands close while talking to people.
Rarely
Very Often
Clear selection
11. Her/his voice is monotonous or dull when he/she talks to people.
Rarely
Very Often
Clear selection
12. He/she uses a variety of vocal expressions when he/she talks to people.
Rarely
Very Often
Clear selection
13. He/she gestures when he/she talks to people.
Rarely
Very Often
Clear selection
14. He/she is animated when he/she talks to people.
Rarely
Very Often
Clear selection
15. He/she has a bland facial expression when he/she talks to people.
Rarely
Very Often
Clear selection
16. He/she moves closer to people when he/she talks to them.
Rarely
Very Often
Clear selection
17. He/she looks directly at people while talking to them.
Rarely
Very Often
Clear selection
18. He/she is stiff when he/she talks to people.
Rarely
Very Often
Clear selection
19. He/she uses a lot of vocal variety when he/she talks to people.
Rarely
Very Often
Clear selection
20. He/she avoids gesturing while he/she is talking to people.
Rarely
Very Often
Clear selection
21. He/she leans toward people when he/she talks to them.
Rarely
Very Often
Clear selection
22.  He/she maintains eye contact with people when he/she talks to them.
Rarely
Very Often
Clear selection
23. He/she tries not to sit or stand too close to people as he/she talks with them.
Rarely
Very Often
Clear selection
24.  He/she leans away from people when he/she talks to them.
Rarely
Very Often
Clear selection
25. He/she smiles when he/she talks to people.
Rarely
Very Often
Clear selection
26. He/she avoids (non-exam related) touching when he/she talks to people.
Rarely
Very Often
Clear selection
Satisfaction with Practitioner
DIRECTIONS: On the measure below, please circle how pleased/satisfied/comfortable you are with your practitioner. Choose one number for each item. Number 4 means "undecided." The closer a number is to the description you think fits best, the stronger you feel about it.
1.
Pleased
Displeased
Clear selection
2.
Dissatisfied
Satisfied
Clear selection
3.
Comfortable
Uncomfortable
Clear selection
Comments
Please clarify or add any further information you find interesting or important about your practitioner's nonverbal behavior and your subsequent satisfaction with him/her.
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