Supplemental Digital Content 1. Questionnaire After-Visit Summary Questionnaire
Background Information:
1. What is your name?
2. What is your date of birth? (mm/dd/yyyy) 3. What is your gender?
a. Male b. Female c. Other
4. With which race do you identify?
a. White
b. Black or African American
c. Native American or American Indian d. Asian/Pacific Islander
e. Other (please specify): ___________
5. With which ethnicity do you identify?
a. Hispanic b. Non-hispanic
6. What is your preferred language?
a. English b. Spanish c. French d. Mandarin e. Cantonese
f. Other: __________
7. What is the highest degree that you have received? If currently enrolled, please select the highest degree received.
a. No schooling completed b. Nursery school to 8th grade
c. High school graduate, diploma or the equivalent (example: GED) d. Trade/technical/vocational training
e. Associate Degree f. Bachelor’s Degree g. Master’s Degree h. Professional Degree i. Doctorate Degree
The after-visit summary is a summary of your visit that may include information such as your diagnosis, medications, medical history, and future visits. You may have been handed this at the end of prior visits.
Please answer the following questions to the best of your ability.
8. Did you receive the after-visit summary at any point in the past year following an ophthalmology visit at this practice?
a. Yes
b. No (please skip to question number 22) c. Unsure (please skip to question number 22) 9. Did you read the after-visit summary?
a. Yes b. No
10. Did someone review the after-visit summary with you while you were in the office at the time of your last visit?
a. Yes b. No
11. Did you find the after-visit summary difficult to understand?
a. Yes b. No
12. Did you find the after-visit summary difficult to read?
a. Yes b. No
13. Did you find the after-visit summary helpful?
a. Yes b. No
14. How many pages was the after-visit summary you received?
15. What did you do with the after visit summary after you received it?
a. Read it b. Threw it away c. Lost it
d. Other: ____________
16. How useful is the after-visit summary in helping you remember which drops to take and how often to take them?
a. Very helpful b. Somewhat helpful
c. Neither helpful nor unhelpful d. Somewhat unhelpful
e. Very unhelpful f. Not applicable
g. No opinion/don’t know
17. How helpful is the after-visit summary in reminding you of your future appointments?
a. Very helpful b. Somewhat helpful
c. Neither helpful nor unhelpful d. Somewhat unhelpful
e. Very unhelpful f. Not applicable
g. No opinion/don’t know
18. Did you refer to the after-visit summary when you had any questions about your medications?
a. Yes b. No
c. I never had questions about my medications
19. Did you refer to the after-visit summary when you had any questions about your future visits?
a. Yes b. No
c. I never had questions about my future visits 20. How often did you refer to the after visit summary?
21. Did you bring the after-visit summary to upcoming appointments?
a. Yes b. No
22. What ocular medications (including eye drops) are you using, how often, and in which eye? (Please specify for each individual eye drop that you use).
23. Is an after-visit summary something you would like to receive?
a. Yes b. No
24. How would you prefer to receive the after-visit summary?
a. Paper (at the end of your visit) b. Electronically
25. If someone was giving you an after-visit summary, which of the following things would you like it to include? Please check all that apply.
__ Your name __ Visit Date __ Provider Name __ Allergies
__ Primary care provider name __ Your diagnosis from today’s visit __ Condition-specific instructions
__ All medical diagnoses (not just in ophthalmology) __ Your full medication list (not just ocular medications) __ Your ocular medications (ie, eye drops)
__ Guidelines for medications
__ Information on how to insert eye drops __ Future visits
26. Please select the font size you would prefer for your eye drop instructions.
a. Option A (size 11)
b. Option B (size 18)
c. Option C (size 24)
d. Even larger
27. How many pages would you like the after-visit summary to be?
a. 1-3 pages b. 4-6 pages c. 7-10 pages
d. However many pages are needed to include all necessary information
28. Please number the following in the order you would like them to appear on your after-visit summary:
__ Your name __ All medical diagnoses (not just in ophthalmology) __ Visit Date __ Your full medication list (not just ocular medications) __ Provider Name __ Your ocular medications (ie, eye drops)
__ Allergies __ Guidelines for medications __ Primary care provider name __ Information on how to insert eye drops __ Your diagnosis from today’s visit __ Future visits
__ Condition-specific instructions
__ If you have no preference, please select this option.
29. How comfortable do you feel in your ability to properly insert eye drops?
a. Very comfortable b. Somewhat comfortable
c. Neither comfortable nor uncomfortable d. Somewhat uncomfortable
e. Very uncomfortable f. Not applicable
g. No opinion/don’t know
30. How often do you miss doses of your ocular medications?
a. Never
b. Rarely (less than one time per year) c. Sometimes (less than one time per month) d. Often (less than one time per week) e. Very often (more than one time per week)
31. What are the most common reasons you miss a dose? Please select all that apply.
a. I forget.
b. I fall asleep.
c. I don’t have my medication(s) with me.
d. My medication(s) are too expensive.
e. My medication(s) cause negative side effects.
f. I have too many medication(s) to keep track of.
g. Other (please specify):
32. Who puts your drops in?
a. Self b. Spouse c. Caregiver
d. Other: ___________
33. Have you received instructions on how to insert eye drops?
a. Yes b. No
34. Would you like to receive instructions on how to insert eye drops?
a. Yes b. No
c. I already received instructions and do not need more instruction.
35. How do you identify the eye drops you are using?
a. Name of medication b. Color of cap
c. Shape of bottle
d. Other (please explain): _____________________________________________
36. How much money do you spend on ocular medications each month?
37. Do you find that these costs prevent you from taking your medication?
a. Yes b. No
38. How many different glaucoma medications do you take?
39. Do you find that the number of medications ever prevents you from taking your eye drops?
a. Yes b. No
40. Do you experience any negative side effects from using your eye drops?
a. Yes b. No
41. What are the side effects from your eye drops that you experience, if any?
42. Do you find that negative side effects prevent you from taking your eye drops?
a. Yes b. No
43. What suggestions for improvement do you have for the way instructions are given in the after-visit summary?
