Informed Consent Study

A Health Care Study Focusing on the Current Level of
Informed Consent in a Clinical Environment


According to the American Medical Association, definite procedures have been established to govern medical office visits in relation to the process of obtaining informed consent from patients.  We are doing a study of people who are currently taking or have recently taken a prescribed medication to gather information about physician-patient communication and the extent of  any informed consent given by the you, the patient, regarding your treatment and any medications you were prescribed.
1.  Are you taking a medication that's been prescribed by a doctor? Yes       No
1a. Have you recently been prescribed a medication by a doctor? Yes       No
1b. Has your child or a child of whom you are the guardian been prescribed a
      medication by a doctor?
Yes       No
2.  Which medication(s)? (enter the medications in the box on the right)
3.  How long was the doctor's visit that resulted in the prescription being written?
4.  What was the reason for your doctor's visit?
5.  What type of doctor did you see?
6.  Were there any physical tests done such as a blood test, urine test or imaging test
      such as an x-ray?
Yes       No
7.  Were you told the diagnosis? Yes       No
8.  Did the doctor explain to you the purpose of the medication? Yes       No
9.  Did the doctor explain to you the risks involved with taking the medication? Yes       No
10.  Were you told about any alternative treatments to taking the suggested
Yes       No
11. If so, were the benefits and risks of the alternatives explained to you? Yes       No
12. Were you told about the risks and benefits of not receiving or undergoing each
      procedure or treatment you discussed?
Yes       No
13. Did the doctor make sure you understood all that was explained to you? Yes       No
14.  Were you invited to ask questions? Yes       No
15.  When you left the doctor's office did you feel you understood what was said well
       enough to make an informed decision about your treatment?
Yes       No
16.  Is there anything else you would like to tell us about your doctor's visit regarding
       informed consent?
17.  If you would like to receive a printed copy of the Rules of Informed Consent and
       be put on our list to receive the results of this study, please enter your e-mail 
       (Please note your answers are kept completely anonymous and private)
Email Address: 

Copy of Rules of Informed Consent
Study Results Before General Release


Informed Consent Study
5132 York Blvd.  #673
Los Angeles, CA  90050