Your Name:* First Last Student Name:* First Last Evaluation Date:* MM slash DD slash YYYY Did the Student Doctor Verify Your Name and Date of Birth:* Yes No Only Verified Name Only Verified Date of Birth Was the Student Doctor’s Appearance Professional:* Yes No If not Professional, Please Leave a Comment Why:*Did the Student Doctor Wash Their Hands Before Examining You? (With Soap/Water or Hand Sanitizer)* Yes No Did the Student Doctor Speak in a Way That Was Easy to Understand:* Yes No Comments:*Did the Student Doctor Show Empathy During the Visit? (Showed they Cared, Empathize over condition, deaths in family, etc.):* Yes No Comments:*During the Visit Did the Student Doctor:Help You Up Onto and Off The Exam Table:* Yes No Maintain Your Modesty (While Adjusting Gown, Placing Drape, Examining, etc):* Yes No Shared Information: Clarified, Summarized, Answered Questions, and Discussed Next Steps**:***next steps: report to attending (first year students) or discuss plan (second year students) Yes No Showed Effective Time Management:* Yes No Would you want this student doctor as your doctor in the future?* Yes No Comment:* Δ