PATIENT SATISFACTION

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* 1. What clinic are you visiting today?

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* 2. Are you new to the Health Center?

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* 3. At today's visit, did the provider:

  Yes No Not Sure I don't want to answer
Spend enough time with you?
Listen carefully to you?
Make you fell comfortable to ask any type of question?
Ask about your physical health (body changes, weight, etc.)?
Ask about your emotional health (feeling sad, stressed, anxious, etc.)
Let you know that certain things you talked about are private (not shared with anyone else)?

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* 4. What do you think about the clinic after your visit?

  Yes No Not Sure I don't want to answer.
I'm comfortable talking with the provider about things (my health, life at home, things that bother me).
I can get information to understand my health.
I know how to contact the clinic if I have any questions or problems.
The front desk staff make me feel welcome.
It's easy to get an appointment today.
I don't have to wait too long for an appointment.

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* 5. What do you think about the clinic space?

  Yes No Not Sure Don't want to answer
The waiting room is comfortable.
It is clean.
It is set up so I can talk with front desk staff without other people hearing me.
The posters and brochures are interesting to me.
Clinic hours are at a time that I can come.

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* 6. Were you happy with your visit today?

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* 7. Would you come back to the clinic?

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* 8. What else would you like to tell us?

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