Department of Family Medicine
PATIENT REQUEST FOR SERVICES SCHEDULE (PRE-VISIT)
INSTRUCTIONS
People hope that [
] can help them in different ways. Some people request help for
medical problems; others request help for non-medical problems. We are interested in
learning how you hope our office can be of help to you today.
Listed on the following two pages are some requests for services that patients have made.
We will ask you to decide HOW IMPORTANT each type of help is to you for TODAY’S visit.
Here are two examples:
Not at all
A Little
Somewhat
Quite a Bit
Very
I want to receive an injection (a shot)…….
c
2
3
4
5
I want to have some blood tests done…....
1
2
e
4
5
Please read each item carefully, and circle a number ranging from 1 (not at all important) to 5
(very important). Please complete all of the questions to the best of your ability. There are
no right or wrong answers. Your doctor will have an opportunity to see your completed
questionnaire before your visit today. Otherwise, your answers will be kept confidential and
this form will not be copied or shared with others.
Thank you very much for your help and cooperation!
A. What is/are the REASON(S) for your visit today?
__________________________________________________________________________
B. Please decide HOW IMPORTANT each type of help is to you for today's visit.
Not at all
A Little
Somewhat
Quite a Bit
Very
I want to share some of my ideas, feelings,
and concerns about my problem with the
doctor……………………………………………...
1
2
3
4
5
2.
I want the doctor to examine me……………….
1
2
3
4
5
3.
I would like the doctor to write a letter and/or
fill out some forms for me……………………….
1
2
3
4
5
I would like some advice about how to stay
healthy (e.g., exercise, diet, rest)………………
1
2
3
4
5
I want the doctor to help me understand more
about my problem so that I can figure out what
to do……………………………………………….
1
2
3
4
5
6.
I want to tell the doctor about the way I’ve
been treating my problem at home…………….
1
2
3
4
5
7.
I want to have some tests done to find out
what’s wrong……………………………………...
1
2
3
4
5
I want something to be done to relieve my
emotional discomfort (e.g., nerves, stress)……
1
2
3
4
5
I want to tell the doctor about some home
remedies or alternative medicines I’ve been
using for my problem…………………………….
1
2
3
4
5
I want the doctor to tell me the name of my
problem…………………………………………...
1
2
3
4
5
I would like to have some screening tests
done to remain healthy…………………….……
1
2
3
4
5
12.
I would like the doctor to treat some other
members of my family…………………………...
1
2
3
4
5
13.
I want the doctor to prescribe medication for
me………………………………………………...
1
2
3
4
5
14.
I would like to tell the doctor what I’m
concerned my problem might be……………….
1
2
3
4
5
I want the doctor to do something to find out if
I have some kind of disease or other condition.
1
2
3
4
5
1.
4.
5.
8.
9.
10.
11.
15.
B. Please decide HOW IMPORTANT each type of help is to you for today's visit. (Continued)
(Circle one number)
Not at all
A Little
Somewhat
Quite a Bit
Very
I would like some help for some personal
emotional problems I am having……………….
1
2
3
4
5
I want the doctor to tell me what caused my
problem……………………………………………
1
2
3
4
5
18.
I want the doctor to help other members of my
family understand more about my problem.…..
1
2
3
4
5
19.
I want something to be done to relieve my
physical discomfort (e.g., pain, cough)………..
1
2
3
4
5
I had some tests done at a previous visit and
I would like to find out my test results………….
1
2
3
4
5
I want the doctor to tell me whether my
problem will get better, continue on, get worse,
or come back again……………………………...
1
2
3
4
5
I would like to tell the doctor what I think
caused my problem……………………...………
1
2
3
4
5
I want to be comforted and feel that someone
cares about me…………………………………..
1
2
3
4
5
I would like to be referred to a specialist for
treatment of my problem………………………...
1
2
3
4
5
I want the doctor to tell me what I can and
what I can’t do while I have this problem……...
1
2
3
4
5
I would like some help for some marital or
family problems I am having…………………
1
2
3
4
5
27.
I want to tell the doctor about how my problem
is affecting my life and family…………………...
1
2
3
4
5
28.
I would like some advice today about some
personal health habits (e.g., how to lose
weight, how to stop smoking, how to control
my drinking)………………………………………
1
2
3
4
5
I am concerned about the health of another
member of my family and would like to speak
to the doctor about this………………………….
1
2
3
4
5
I would like the doctor to work with another
healer I am seeing for this problem……………
1
2
3
4
5
16.
17.
20.
21.
22.
23.
24.
25.
26.
29.
30.
C. DEMOGRAPHICS
Now, we'd just like to obtain a little bit of information about you and your family.
1. Birthdate (Month/Day/Year) _______/_______/_______
2. Sex (Check one)
… Male
… Female
3. Current Marital Status (Check all that apply)
… Single (Never married)
… Separated
… Single
… Divorced
… Married
… Widow/Widower
… Other ____________
4. Children (Check one)
… No
… Yes
5. Education (Highest number of years completed) ___________
6. Employment (Check all that apply)
… Currently employed full-time
… Full-time housewife/househusband
… Currently employed part-time
… Full-time student
… Currently between jobs
… Other ______________
OPTIONAL: Year 2000 Census categories
7. Ethnicity (Check one)
… Latino or Hispanic – NO
… Latino or Hispanic – YES
8. Race (Check all that apply)
… White
… Black or African American
… American Indian or Alaska Native
… Asian
… Native Hawaiian or Other Pacific Islander
… Not Classifiable or Unknown
… Other ______________
THANK YOU VERY MUCH FOR YOUR HELP AND COOPERATION!
D CODE: ______
P CODE: ______