Dartmouth : Seminar IV - Evaluation Form

Please take a few minutes to evaluate today's workshop.
Scale: 1=Yes, definitely 2=Yes, a lot 3=Yes, somewhat 4= Hardly at all 5=No, definitely not

ADVANCE DIRECTIVES CONTINUED

Did you work on the Advance Directives at home?	1	2	3	4	5
Was the information in this session about having conversations and sharing Advance Directives useful?	1	2	3	4	5
Do you feel better able to discuss your values and preferences with your health care providers?	1	2	3	4	5
Do you feel better able to discuss your values and preferences with your family/ friends?	1	2	3	4	5

UNFINISHED BUSINESS

Do you feel you have unfinished business?	1	2	3	4	5
Was the exercise today helpful in identifying unfinished business?	1	2	3	4	5
Will you talk about unfinished business with your health care providers?	1	2	3	4	5
Will you talk about unfinished business with your family/friends?	1	2	3	4	5

PROCESS OF GRIEF

Are you experiencing problems around grief and loss?	1	2	3	4	5
Do you feel after today you have more information about the experience of grief and loss?	1	2	3	4	5
Will you talk about your feelings of grief and loss with your health care providers?	1	2	3	4	5
Will you talk about your feelings of grief and loss with your family/friends?	1	2	3	4	5

LISTENING

Do you feel listened to and able to listen to others?	1	2	3	4	5
Will the information we provided today about listening be useful?	1	2	3	4	5
Will you use listening skills and ask to be listened to with your health care providers?	1	2	3	4	5
Will you use listening skills and ask to be listened to with family / friends?	1	2	3	4	5

COMMENTS:

Date:________________
Patient
Support Person
Name (optional):____________________

This content is derived from the "Charting Your Course Seminars: A Whole Person Approach To Living With Cancer", provided by Norris-Cotton Cancer Center.