Patient Survey Question Title * 1. 1. Our records show that you got care from the provider named below in the last 12 months. (Circle one or more) • Dr Inderpal Chhabra • Dr Dalbir Chhabra • Sumam Cheekaparayil, NP Question Title * 2. 2. Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt? Yes No Question Title * 3. 3. How long have you been going to this provider? • Less than 6 months • At least 6 months but less than 1 year • At least 1 year but less than 3 years • At least 3 years but less than 5 years • 5 years or more Question Title * 4. 4. In the last 12 months, how many days did you usually have to wait for an appointment when you needed care right away? Same day 1 day 2 to 3 days•4 to 7 days More than 7 days Question Title * 5. 5. In the last 12 months, did you make any appointments for a check-up or routine care with this provider? • Yes • No → If No, go to #8 Question Title * 6. 6. In the last 12 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed? • Never • Sometimes • Usually • Always Question Title * 7. 7. Did this provider’s office give you information about what to do if you needed care during evenings, weekends, or holidays? • Yes • No Question Title * 8. 8. In the last 12 months, did you get any reminders such as visits about tests, treatment or appointments from this provider’s office between visits? • Yes • No Question Title * 9. 9. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see this provider within 15 minutes of your appointment time? • Never • Sometimes • Usually • Always Question Title * 10. 10. In the last 12 months, how often did this provider explain things in a way that was easy to understand? • Never • Sometimes • Usually • Always Question Title * 11. 11. In the last 12 months, how often did this provider seem to know the important information about your medical history? • Never • Sometimes • Usually • Always Question Title * 12. 12. In the last 12 months, how often did this provider show respect for what you had to say? • Never • Sometimes • Usually • Always Question Title * 13. 13. In the last 12 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results? • Never • Sometimes • Usually • Always Question Title * 14. 14. In the last 12 months, did you and this provider talk about starting or stopping a prescription medicine? • Yes • No → If No, go to #16 Question Title * 15. 15. When you talked about starting or stopping a prescription medicine, how much did this provider talk about the reasons you might want to take a medicine? • Not at all • A little • Some • A lot Question Title * 16. 16. In the last 12 months, how often did the provider named in Question 1 seem informed and up-to-date about the care you got from specialists? • Never • Sometimes • Usually • Always Question Title * 17. 17. When you talked about starting or stopping a prescription medicine, how much did this provider talk about the reasons you might not want to take a medicine? • Not at all • A little • Some • A lot Question Title * 18. 18. When you talked about starting or stopping a prescription medicine, did this provider ask you what you thought was best for you? • Yes • No Question Title * 19. 19. 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? • 0 Worst provider possible • 1 • 2 • 3 • 4 • 5 • 6 • 7 • 8 • 9 • 10 Best provider possible Question Title * 20. 20. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 12 months, did you see a specialist for a particular health problem? • Yes • No: If No, go to #22 Question Title * 21. 21. In the last 12 months, how often did the provider named in Question 1 seem informed and up-to-date about the care you got from specialists? • Never • Sometimes • Usually • Always Question Title * 22. 22. In the last 12 months, did anyone in this provider’s office talk with you about specific goals for your health? • Yes • No Question Title * 23. 23. In the last 12 months, did anyone in this provider’s office ask you if there are things that make it hard for you to take care of your health? • Yes • No Question Title * 24. 24. In the last 12 months, did you take any prescription medicine? • Yes • No → If No, go to #26 Question Title * 25. 25. In the last 12 months, did you and anyone in this provider’s office talk at each visit about all the prescription medicines you were taking? • Yes • No Question Title * 26. 26. In the last 12 months, did anyone in this provider’s office ask you if there was a period of time when you felt sad, empty, or depressed? • Yes • No Question Title * 27. 27. In the last 12 months, did you and anyone in this provider’s office talk about things in your life that worry you or cause you stress? • Yes • No Question Title * 28. 28. In the last 12 months, did you and anyone in this provider’s office talk about a personal problem, family problem, alcohol use, drug use, or a mental or emotional illness? • Yes • No Question Title * 29. 29. In the last 12 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be? • Never • Sometimes • Usually • Always Question Title * 30. 30. In the last 12 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect? • Never • Sometimes • Usually • Always Question Title * 31. 31. In general, how would you rate your overall health? • Excellent • Very Good • Good • Fair • Poo Question Title * 32. 32. In general, how would you rate your overall mental or emotional health? • Excellent • Very Good • Good • Fair • Poor Question Title * 33. 33. What is your age? • 18 to 24 • 25 to 34 • 35 to 44 • 45 to 54 • 55 to 64 • 65 to 74 • 75 or older Question Title * 34. 34. Are you male or female? • Male • Female Question Title * 35. 35. 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 * 36. 36. What is your race? Mark one or more. • White • Black or African American • Asian • Native Hawaiian or Other Pacific • Islander • American Indian or Alaskan • Native • Other Question Title * 37. 37. Did someone help you complete this survey? • Yes • No → If yes, go to #38 Question Title * 38. 38. How did that person help you? Mark one or more. • Read the questions to me • Wrote down the answers I gave • Answered the questions for me • Translated the questions into my language • Helped in some other way Please print: ______________________________________________________ Done