Please answer Yes or No to each of the following ten questions and check all boxes that apply to your situation. A pdf report of your unique decision support needs will be generated once you press the "submit" button

The Decision I need to make is:

Time frame for making this decision:

Options I have:

I would like help from family, friends, or providers in making this decision:

If yes, list people you want to be involved

If Yes to the above, list person(s) here

Location of Papers

Location of document

1. I feel I have the basic facts I need to make this decision

2. I have asked about, understand, and considered the risks and benefits of treatment


List Treatment Pros:

List Treatment Cons:

I may have concerns about the following:

3. I know what might happen if I decide not to have treatment

I need to:

4. I would like to have a second opinion about my diagnosis and/or treatment

- Continue to the next question

5. All my questions have been answered and I know what treatment will be like

- Continue to the next question

6. I know who to contact if new questions come up

I need to:

7. I have thought about personal preference and life quality issues (what matters to me)

Things I need to consider:

8. I understand I can make the decision based on my own needs, not those of others

9. I may have doubts about my decision

10. I have or need the following support

Help with transportation

Help with medications

Help with household duties (Meals, bills, housework)

Help with doctor visits

Help communicating with providers

Help filling out insurance/benefit forms

Help figuring out the financial impact

Emotional support

Thank You for Completing the Decision Support Questions!

The next step is for you to generate and control your own data by viewing, saving, printing, and/or sharing your report with your family, advocates, or providers. The report functions as a common starting point to help you move forward successfully in the decision-making process.

It can be difficult to speak up during medical visits and to communicate your unique needs and preferences to your family, friends, and providers. This tool assists with the challenges of patient-provider interaction, time constraints, and the need to remember every detail and all of your questions during fast-paced office visits.

The report provides a streamlined color-coded list of areas where you feel confident and decisive – and areas in which you may need support and guidance.

Green column - The patient has made a decision or feels confident in these matters.

Orange column – Actions the patient needs to take to complete the decision-making process.

Red column – Identifies issues that may require assistance from your providers.

View Your Results

Please note: Do not include any personal information in the text boxes contained in this app, including date of birth, social security number, or address. Information in this app is not encrypted and is not guaranteed to be secure when sent via email. Information is not stored on our server and is never shared with anyone. This app is not intended to replace the advice of your health care providers, but to strengthen the shared decision-making process and to help further the goal of patient-centered care.