Horizon Family Medical Group Question Title * 1. Please Select the location of your most recent visit: Chester Cornwall - Quaker Ave Cornwall - Rte. 9W Cornwall - Ophthalmology Cornwall - Women's Health Florida Goshen Goshen - GI - 30 Hatfield Lane, Ste 107 Goshen - GI - 30 Hatfield Lane, Ste 103 Goshen - Nephrology Goshen - Ophthalmology Goshen - Surgery Goshen - Ste 105 Women's Health Goshen - Ste 207 Women's Health Highland Falls Highland Falls - Women's Health Maybrook Middletown - Endoscopy Suite Monroe Monroe - Endocrinology Monroe - Gastroenterology Newburgh - Dermatology Newburgh - Nephrology Newburgh - Ophthalmology Newburgh - Surgery NW - Family - Little Britain Road NW - Family - Oakwood Terrace NW - Family - 92 Old Route 9W New Windsor - Endocrinology New Windsor - Endoscopy Suite New Windsor - Gastroenterology New Windsor - Pulmonary New Windsor - 270 Quassaick Slate Hill STAGES Warwick - Grand Str. Warwick - Gastroenterology Warwick - Women's Health Washingtonville Warwick - Maple Ave. Other (please specify) Question Title * 2. When you made your most recent appointment with Horizon Family Medical Group, were we able to meet your date and time preference? Yes No Question Title * 3. What is your Age? <65 >=65 Question Title * 4. Were your expectations met during your last visit? Yes No Question Title * 5. How satisfied were you with the courteousness/friendliness of our front desk during your visit? Satisfied Somewhat Satisfied Dissatisfied Question Title * 6. How satisfied were you with the courteousness/friendliness of our nurses during your visit? Satisfied Somewhat Satisfied Dissatisfied Question Title * 7. How satisfied were you with the time you waited before you were seen by your provider? Satisfied Somewhat Satisfied Dissatisfied Question Title * 8. How satisfied were you with the courteousness/caring of your provider during your visit? Satisfied Somewhat Satisfied Dissatisfied Question Title * 9. How well did your doctor listen to you during your visit? Well Slightly well Not at all well Other (please specify) Question Title * 10. How well did your doctor explain how to take your medicine(s)? Well Slightly well Not at all well Question Title * 11. How satisifed were you with the self-care management tools given to you at your appointment?(example: patient literature,referral information, classes) Satisfied Dissatisfied Not Applicable Question Title * 12. How satisfied overall are you with the level of care you received during your last visit? Satisfied Somewhat Satisfied Dissatisfied Question Title * 13. Did any Horizon staff member make your visit/interaction today extra special or meaningful? If so, please indicate the name of the person: Question Title * 14. Do you ever recommend Horizon Family Medical Group to family and friends? Yes No Question Title * 15. What, if anything, would you like to see done differently or what could be done to improve the service you received from Horizon Family Medical Group? Question Title * 16. If you were referred to a specialist, did your primary care provider explain to you why you were being referred to a specialist? Yes No Somewhat Question Title * 17. If you were referred to a specialist, did the specialist have all your necessary health history information, such as lab or x-ray results and your medication list prior to your arrival? Yes No Somewhat Question Title * 18. If you were referred to a specialist, did they communicate their findings back to your primary care doctor? Basically did you get a sense that the two doctors were communicating with each other? Yes No Somewhat Question Title * 19. For patients who were hospitalized within the past 12 months: Did the Horizon care transition RN visit you and advocate for you during your hospital stay? Yes No Question Title * 20. For patients who were hospitalized within the past 12 months: When you left the hospital, did you know how to reach the Horizon care transition RN with any questions or concerns? Yes No Question Title * 21. For patients who were hospitalized within the past 12 months: Did you receive a call from your Horizon care transition RN to discuss your discharge instructions and medications? Yes No Question Title * 22. For patients who were hospitalized within the past 12 months: Did you know that the Horizon care transition RN is available post hospital discharge for any questions or concerns? Yes No Question Title * 23. For patients who were hospitalized within the past 12 months: Did the Horizon care transition RN schedule your follow up appointment post discharge? Yes No Question Title * 24. Have you visited your (PCP) Primary Care Provider this year for your annual physical? Yes No Question Title * 25. Have you and your provider discussed ways for you to maintain/improve your health, such as eating healthy, ways to stay active, or taking medications? Yes No Question Title * 26. Did you (or will you) get a flu vaccination this season? Yes No Question Title * 27. (age 65+) Have you ever had a pneumonia vaccination? Yes No N/A Done
