CASE 2 - CROSS-CULTURAL CARE SCORING FORM

First Name:
Last Name:
Student ID:

Content Checklist
Bleeding gums	select answerYesNo
Gum pain while bushing	select answerYesNo
Began a month ago	select answerYesNo
Had history of periodontal treatment	select answerYesNo
20 weeks pregnant	select answerYesNo
Wants to postpone any treatment until after delivery	select answerYesNo
Concerns about effects of treatment on fetus	select answerYesNo
Student explains the need for perio exam and possible treatment before delivery	select answerYesNo
Student explains the association between periodontitis and low-weight pre-term birth	select answerYesNo
Association between pregn hormones and gingivitis	select answerYesNo
No medication, unremarkable medical history	select answerYesNo
Takes multivitamins	select answerYesNo
No ongoing medical problems	select answerYesNo
No illicit drugs	select answerYesNo
Brushes once daily; flosses only when food stuck in teeth	select answerYesNo
Dental insurance through husband	select answerYesNo
Heritage is South Korean	select answerYesNo
Does not want an interpreter unless complicated instructions	select answerYesNo
Nonsmoker, no ETOH concerns	select answerYesNo
Using Korean maternity practices	select answerYesNo
Homemaker	select answerYesNo
Soc sup	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
Pacing of Interview	select answer12345
Types of Questions	select answer12345
Summarizing	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
Patient's Education and Understanding	select answer12345
Encouragement of Questions	select answer12345
Closure	select answer12345