| Presented all of the reasonable treatment/intervention options to patient: | |
| Discussed the risks and benefits of each option with patient: | |
| Asked patient to review relevant decision tools (booklets/videos/Web sites): | |
| Asked patient to teach back what was discussed: | |
| Patient demonstrated an understanding of the options: | |
| Encouraged patient to talk about what matters most to him/her: | |
| Listened actively to patient and asked open-ended questions: | |
| Asked patient how his or her decision might impact their daily life: | |
| Acknowledged and agreed with my patient on what matters most to him/her: | |
| Asked patient what option he/she preferred: | |
| Asked patient, if he/she needed additional information: | |
| Asked patient, if he/she wanted to consult others before making a decision: | |
| Patient and Treating Doctor agreed on the decision: |