Healthcare Expertise Questionnaire

HEALTHCARE EXPERTISE QUESTIONNAIRE

Purpose: This questionnaire collects patient identification, clinical background and any professional healthcare expertise the patient or their designee may hold. Information provided will be used to assess clinical communication needs, informed consent capacity, and to document relevant credentials. All responses must be complete and truthful. False statements may have legal consequences.

Patient Information

Date of birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Functional and Cognitive Status

Requires mobility assistance: Yes    No

Cognitive impairment or memory concerns: Yes    No

Healthcare Experience and Professional Expertise

Are you currently or formerly employed in healthcare? Yes    No

Have you participated previously as an expert witness, clinical consultant, or clinical instructor? Yes    No

Assessment of Medical Knowledge and Consent Capacity

I represent that my level of medical understanding regarding my condition and proposed treatments is:
Full understanding    Partial understanding    Little or no understanding

Do you feel able to participate in informed consent discussions and make healthcare decisions? Yes    No

Privacy, Authorization and Attestation

By signing below I acknowledge: I have provided information that is true and complete to the best of my knowledge. I authorize my healthcare providers to use this information to inform my care. I understand that I may revoke this authorization in writing except to the extent that action has already been taken in reliance upon it.

HIPAA privacy acknowledgment: I acknowledge receipt of the facility's privacy notice and understand my rights with respect to protected health information.

Warning: Deliberate falsification or omission of material facts may result in denial of services, withdrawal of privileges, or other legal remedies as permitted by law.

Sign Now