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AAD QI Tool Pilot — Patient Survey

Enter responses from the paper Patient Survey. Only patient ID and survey date are required; leave other questions blank if the patient did not answer them.

Entered today

0

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New Entry

Instrument v2

Patient ID *

Practice-local identifier from the paper form.

Survey Date *

Date on the paper form.

What is the medical condition you were seen for today??

Plaque psoriasis

Hidradenitis suppurativa

Alopecia areata

Did your doctor or care team share the Shared Decision Making (SDM) Aid with you today?

Yes

No

Not sure/Can't remember

Was this the first time you were shown the SDM Aid handout?

Yes

No

Not sure/Can't remember

How clear was the explanation about the purpose of the SDM Aid?

Very clear

Fairly clear

Not clear / did not understand

Wasn't given an explanation

Not sure/Can't remember

Was the SDM Aid easy to read and understand?

Very easy

Somewhat easy

Not very easy

Difficult

Not sure/Can't remember

segment Overall, how helpful was the SDM Aid in helping you to:

How helpful was the SDM Aid in helping you to talk with your clinicians about choosing a treatment?

Very helpful

Somewhat helpful

Not sure

Not very helpful

Not helpful at all

How helpful was the SDM Aid in helping you to understand the treatment advice?

Very helpful

Somewhat helpful

Not sure

Not very helpful

Not helpful at all

How helpful was the SDM Aid in helping you to make a treatment decision that is right for you?

Very helpful

Somewhat helpful

Not sure

Not very helpful

Not helpful at all

How helpful was the SDM Aid in helping you to feel confident in the treatments selected?

Very helpful

Somewhat helpful

Not sure

Not very helpful

Not helpful at all

Did you appreciate discussing treatment options with your doctor?

Happy to discuss

Not happy to discuss

Neither happy nor unhappy

Didn't discuss but would have liked to

Didn't want to — doctor knows best

Which topics helped you decide which medication to try? (Check all that apply)

Hair regrowth / skin clearance goals

Other medical conditions

Speed of medication results

How to take the medication

Side effects

Cost / affordability

How quickly I can get the medication

How to help with prior authorization

Not applicable

I don't remember

Other