Signature: ———    Date: ———

(1) Do you want physical touching of your body by doctor during consultation?

(a) Yes

(b) No

(c) Don't know

(2) Do you approve physical touching of your body by doctor during consultation?

(a) Yes

(b) No

(c) Don't know

(3) Do you feel comfortable with physical touching of your body by doctor during consultation?

(a) Yes

(b) No

(c) Don't know

(4) You would take a touch from a doctor during consultation as a gesture of?

(a) Empathy

(b) Cure

(c) Respect

(d) Comfort

(e) Communication with doctor

(f) Other ———

(5) Which part of your body you would comfortable with?

(a) Hand

(b) Head

(c) Shoulder

(d) Knee

(e) Upper back

(f) Other ———

(6) Which part of your body you will not be comfortable with?

(a) Abdomen

(b) Thigh

(c) Others ———

(7) Do you feel comfortable with his/her eye contact?

(a) Yes

(b) No

(c) Don't know

(8) For how long should an eye contact be?

(a) Should be throughout consultation

(b) Should be brief but regular

(c) Should be more at beginning less in the end

(d) Should be more at endless in the beginning

(e) Others ———

(9) What do you feel when a doctor makes an eye contact?

(a) Confidence in yourself

(b) Confidence in communication

(c) Secure

(d) Attended

(e) Much more important

(f) Other ———

(10) What are the things which would make you uncomfortable during eye contact?

(a) Long stare

(b) Smiling eyes

(c) Frequent blinking

(d) Others———

(11) What do you feel if a doctor does not make an eye contact?

(a) Religious

(b) Less confident

(c) Short attention span

(d) Liar

(e) Lack of interest