CASE 1 - HEALTH BELIEFS SCORING FORM

First Name:
Last Name:
Student ID:

Content Checklist
Several painful and "abscessed teeth"	select answerYesNo
Fillings were removed due to "reaction to mercury" 2 years ago	select answerYesNo
History of chemical sensitivity	select answerYesNo
Multiple diffuse physical symptoms	select answerYesNo
Seeks "alternative" medical care (ecologist, diagnostics, etc.)	select answerYesNo
Worked as a nurse, currently on disability	select answerYesNo
Only natural products (vitamins, minerals, body care products)	select answerYesNo
Allergy to latex	select answerYesNo
Fearful of reaction to local anesthetics	select answerYesNo
Demands no amalgam restorations	select answerYesNo
Brushes daily	select answerYesNo
Baking soda	select answerYesNo
Uses nasal oxygen when outside of home	select answerYesNo
Wisdom teeth removed 15 years ago and regular care throughout life, until diagnosis	select answerYesNo
Not married	select answerYesNo
Mother only support, is 78 and has adult onset diabetes	select answerYesNo
Relies on others for transportation	select answerYesNo
Concerns with traditional dental approaches	select answerYesNo
Concerns with environmental exposures	select answerYesNo

MIRS
Opening	select answer12345
Elicits Spectrum of Concerns	select answer12345
Negotiates Priorities and Sets Agenda	select answer12345
Eliciting the Narrative Thread or the "Patient's Story"	select answer12345
Timeline	select answer12345
Organization	select answer12345
Transitional Statements	select answer12345
Pacing of Interview	select answer12345
Types of Questions	select answer12345
Summarizing	select answer12345
Duplication	select answer12345
Lack of Jargon	select answer12345
Verification of Patient Information	select answer12345
Verbal Facilitation Skills	select answer12345
Non-Verbal Facilitation Skills	select answer12345
Empathy and Acknowledging Patient Cues	select answer12345
Patient's Perspective (Beliefs)	select answer12345
Support Systems	select answer12345
Encouragement of Questions	select answer12345
Closure	select answer12345