VA Form 10-0550 Psychiatric Patient Satisfaction Survey

Michael E. DeBakey VAMC

Psychiatric Patient
Satisfaction Survey
OMB 2900-0770
Estimated Burden: 1 min.

VA Form 10-0550

PRA Statement: This information is collected in accordance with section 3507 of the Paperwork
Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to
respond to a collection of information unless it displays a valid OMB number. We anticipate that
the time expended by all individuals who complete this consent form will average 1 minute. This
includes the time it will take to read information provided and complete the form. Submission of this
form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Psychiatric Patient Satisfaction Survey
Patient Feedback Form v1

Print Form

Date

Patient review of Dr.
Physician Specialty - Please select one:

Psychiatry

Neurology

Child Neurology

PERFORMANCE RATINGS

The following guidelines are to be used in selecting the appropriate rating:
Please select a performance rating
for your doctor for each of the
following statements:

1

2

3

4

5

6

Never

Rarely

Occasionally

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2

3

4

5

6

1

2

3

4

5

6

1

2

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4

5

6

1

2

3

4

5

6

5

6

Frequently Always Not Applicable

1) Physician listens carefully to your symptoms.

2) Physician asks questions regarding your health history.

3) Physician explains tests that he/she ordered.

4) Physician discusses treatment options with you, including the expected course of treatment.
1

2

3

4

5) Physician explains drugs and other treatments (for example, psychotherapy), their expected effects,
and possible side effects.
1

2

3

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6

3

4

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6

2

3

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5

6

2

3

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5

6

3

4

5

6

2

3

4

5

6

2

3

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5

6

6) Physician discusses the treatment costs, insurance, and payment options with you.
1

2

7) Physician encourages you to ask questions about your treatment.
1
8) Physician answers questions to your satisfaction.
1

9) Physician gives you advice on what to do if symptoms persist or worsen.
1

2

10) Physician refers you to another specialist when necessary.
1
11) Physician tells you when to schedule a return visit.
1
12) Physician treats you in a professional manner.
Please Return Completed Form To Physician For His/Her Confidential Records - Do Not Send to the ABPN

VA Form 10-0550
MAY 2012

OMB 2900-0770
American Board of Psychiatry and Neurology, Inc., 2150 E. Lake Cook Road, Suite 900, Buffalo Grove, IL 60089
Estimated Burden: 1 min.
Ph: 847.229.6500 Fax: 847.229.6600 www.abpn.com