What Matters To Me Questionnaire

We are trying to create a tool to help patients communicate with their physicians and other care providers about what really matters to them in their relationships with the health care system. Although one may not always get everything wishes for, this is a chance to share your preferences and values with regards to the healthcare you receive.
When answering the questions it may be helpful to think of times you felt that your medical care needs were not met. Please rate choices in the order of importance to you.
All information is confidential. No one’s identity will be shared with anyone.

Thank you for helping us!

Sosena Kebebe, M.D., M.P.H., Baltimore, Maryland
David Elpern, M.D., Williamstown, Massachusetts
Hope Mendez, Research Assistant (Williamstown, Massachusetts)

Demographic Information

Age:________

Sex (please circle):  M  F  Trans

Ethnicity: (please circle)
African-American
Asian
Hispanic
Native American
White
Other: ­­­­­­­­­_____________________________

Highest Level of Education: (please circle)
Grade School
High School Graduate
Some College
College Graduate
Postgraduate degree

Insurance (please circle):
Private
Medicaid
Medicare
None
Other

What Matters To Me Questionnaire

Please circle what is important to you and rate those choices in the order of importance to you.

Question 1. When interacting with your physicians which qualities do you value the most:

1. Knowledge
2. Kindness
3. Being on time
4. Efforts to connect with me as a human being and not just as a patient

1. Listening skills
2. Involving me in decision-making
3. Spending adequate time with me
4. Explaining things fully and in the way I understand them

1. Other : __________________________________________________________

2. My personal responsibility for my health is:
3. Learn as much as I can about my condition and be actively involved in decision making
4. Exercise, diet and lead a healthy lifestyle
5. Follow medical recommendations given
6. Other:__________________________________________________________

3. Regarding labs or diagnostic tests that my doctor may recommend:
4. I only want the absolute critical tests to be performed
5. I want all the tests that could be helpful to understand my condition better
6. I want to understand how important they are before I get them done
7. Other:___________________________________________________________

4. Regarding medications that my doctor may prescribe:
5. I want to know exactly what I am taking and why
6. I want the absolute minimum that I need to take for my condition
7. I want to take anything that can possibly help my condition
8. I want to understand the side effects of each medication thoroughly before accepting the prescription
9. I want the freedom to try alternative medicine and herbal supplements

5. Regarding my overall healthcare expenses including cost for medications and tests:
6. I want to know exactly what I am being charged for
7. I want to know what my health insurance covers
8. I want to minimize my healthcare expenditure
9. I am willing to spend whatever I need to take care of my health

6. Additional Comments. What else matters to you? (you may use this space to describe things that you wish were better in the way healthcare is delivered): _______________________________________________________________________

______________________________________________________________________­_