| Rating | 0 | 1 | 2 | 3 |
| Self-assessment | ¨ | ¨ | ¨ | ¨ |
| Doctor-assessment |
|
|
|
|
| Doctor A | ¨ | ¨ | ¨ | ¨ |
| Doctor B | ¨ | ¨ | ¨ | ¨ |
| Total Score |
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