Pediatric Healthcare of LI Survey

Question Title

* In the last 12 months, how often did the clerks and receptionists at this office treat you with courtesy and respect?

Never

Sometimes

Usually

Always

Question Title

* In the last 12 months, how many days did you usually have to wait for an appointment when your child needed care right away?

Same day

1 day

2 to 3 days

4 to 7 days

More than 7 days

N/A

Question Title

* In the last 12 months, how often were you able to get the care your child needed from our office during evenings, weekends, or holidays?

Never

Sometimes

Usually

Always

N/A

Question Title

* Please identify the physician who you consider your primary doctor or the physician who your child has seen or spoken to most often over the past 12 months and answer the following questions about that doctor.

Diane Aranda

Abraham I Green

Jamie Lanzillotta

Moshe Schlusselberg

Howard Slomko

Ingrid Soltys

Question Title

* In the last 12 months, how often did your child see this provider within 15 minutes of his or her appointment time?

Never

Sometimes

Usually

Always

N/A

Question Title

* In the last 12 months, how often did this provider seem to know the important information about your child's medical history and seem informed and up to date about the care your child received from any specialists?

Never

Sometimes

Ususally

Always

N/A

Question Title

* In the last 12 months, did this provider talk about the following topics?

	Yes	No	N/A
Your child's learning ability?	Your child's learning ability? Yes	Your child's learning ability? No	Your child's learning ability? N/A
Behaviors that are normal for your child at this age?	Behaviors that are normal for your child at this age? Yes	Behaviors that are normal for your child at this age? No	Behaviors that are normal for your child at this age? N/A
How's your child's body growing?	How's your child's body growing? Yes	How's your child's body growing? No	How's your child's body growing? N/A
Your child's moods and emotions?	Your child's moods and emotions? Yes	Your child's moods and emotions? No	Your child's moods and emotions? N/A
How to keep your child from getting injured?	How to keep your child from getting injured? Yes	How to keep your child from getting injured? No	How to keep your child from getting injured? N/A
How much time your child spends on a computer and in front of a TV?	How much time your child spends on a computer and in front of a TV? Yes	How much time your child spends on a computer and in front of a TV? No	How much time your child spends on a computer and in front of a TV? N/A
How much or what kind of food your child eats?	How much or what kind of food your child eats? Yes	How much or what kind of food your child eats? No	How much or what kind of food your child eats? N/A
How much or what kind of exercise your child gets?	How much or what kind of exercise your child gets? Yes	How much or what kind of exercise your child gets? No	How much or what kind of exercise your child gets? N/A

Question Title

* In the last 12 months, when a blood test, x-ray, or other test was ordered for your child, how often did someone from this provider’s office follow up to give you those results?

Never

Sometimes

Usually

Always

N/A

Question Title

* In the last 12 months, how often did this provider give you easy to understand information about health questions or concerns you had?

Never

Sometimes

Usually

Always

N/A

Question Title

* In the last 12 months, how often did this provider show respect for what you had to say?

Never

Sometimes

Usually

Always

N/A

Question Title

* In the last 12 months, how often did this healthcare provider listen carefully to you?

Never

Sometimes

Usually

Always

N/A

Question Title

* In the last 12 months, how often did this provider explain things in a way that was easy for your child to understand?

Never

Sometimes

Usually

Always

N/A

Question Title

* In the last 12 months, how often did this provider spend enough time with you and your child?

Never

Sometimes

Usually

Always

Question Title

* Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

	Worst provider possible									Best provider possible
.	. Worst provider possible	.	.	.	.	.	.	.	.	. Best provider possible

Question Title

* What is your child's age?

Less than 1 year old

Years old (write in)

Question Title

* Is your child male or female?

Male

Female

Question Title

* What is your race? Please choose one or more.

White

Black or African-American

Asian

Native Hawaiian or other Pacific Islander

American Indian or Alaska Native

Hispanic or Latino origin or descent

Other

Question Title

* What is your age?

Under 18

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

Question Title

* What is the highest grade or level of school that you have completed?

8th grade or less

Some high school, but did not graduate

High school graduate or GED

Some college or 2-year degree

4-year college graduate

More than 4-year college degree

Question Title

* How are you related to the child?

Mother or father

Grandparent

Aunt or uncle

Older brother or sister

Other relative

Legal guardian

Someone else

Question Title

* Thank you for taking the time to complete this survey. We need your feedback to determine the best ways to improve the care of the children, adolescents and parents in our practice. Please add any comments or suggestions in the space below.