Promoting Excellence : Patient Questionnaire (UCSF)

University of California San Francisco Comprehensive Care Team: Patient Questionnaire

This is a written survey to assess demographics, physical symptoms (especially pain and dyspnea), emotional and spiritual well-being, health care utilization, and advance directive planning for patients with serious illness.

Evaluation - Satisfaction/Perception of Care

University of California San Francisco
Comprehensive Care Team
1600 Divisadero Street, Room C-433
San Francisco, CA 94115-1640

Michael Rabow, MD
[email protected]

How the grantee used this instrument:
Self-administered survey given prior, half-way through, and after the 1-year Comprehensive Care Team intervention. Given the illness burden of respondents, completion required approximately 1.5-2 hours and generally required the assistance of a research associate to ensure accuracy and completeness.

congestive heart failure, COPD, cancer, patient experience, patient perception of care, patient satisfaction

To use this tool:
You may print this tool for review from this site. This tool draws items from several published instruments (see references below). You must seek permission from the original authors before using this tool.


To view this tool:
Left click on the download link to view the PDF document in your Web browser. Right-click on the download link to save the document to your computer. Viewing PDF files requires downloading and installation of the free Adobe Acrobat Reader.
pdf PDF 845 KB / 24 pages

Posted September 2003

University of California, San Francisco overview page

# UCSF6, type:satisfaction/perception_care

Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying people and their families. Visit for more resources.

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