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Medical doctors are always rated by other medical doctors. Now is your chance as a health care consumer to choose the best alternative medicine doctor in America. If you know an exceptional alternative medicine provider or practitioner, complete the following questionnaire.

Please Note: Incomplete or inaccurate questionnaires will be disqualified from consideration. Contact information is required for verification purposes but will be kept strictly confidential (see Privacy Policy). Results of the survey may be posted on this Site or used in other media.

Survey

Name of Dr/Practitioner	Address	Area code/Phone #

City	State	Zip Code

Alternative Specialty(s) or Interest(s) - acupuncture, homeopathy, etc.

Your Name	Area code/Phone #	Email Address

Rate the following selections for the provider you are nominating from 1 to 5
(1= poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent):

		1	2	3	4	5
1.	knowledge of alternative medicine speciality
2.	skill in alternative techniques or therapies
3.	experience in alternative medicine speciality
4.	communication skills - good listener & easy to understand
5.	bedside manner - kindness, sensitivity & respect for your needs
6.	punctuality - on time for appointments & responding to inquiries
7.	ability to place your interests & problems first
8.	willingness to answer all questions to your satisfaction
9.	support for healthy self-care & lifestyle habits - diet, exercise, etc.
10.	support for realistic physical, mental, or lifestyle change
11.	willingness to provide information about remedies & treatments
12.	willingness to discuss other treatment options
13.	willingness to refer to practices other than his/her own
14.	accessibility - time in scheduled visits & availability outside visits
15.	support for equal partnership with patient

Modified 11.9.07

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