* 1. Gender

* 2. Age

* 3. Care Team

* 4. The last time you were sick, how many days did it take from when you first tried to see your doctor or nurse practitioner to when you actually SAW him/her or someone else in their office?

* 5. When you see your doctor or nurse practitioner, how often do they or someone else in the office give you an opportunity to ask questions about recommended treatment?

* 6. When you see your doctor or nurse practitioner, how often do they or someone else in the office involve you as much as you want to be in decisions about your care and treatment?

* 7. When you see your doctor or nurse practitioner, how often do they or someone else in the office spend enough time with you?

* 8. In general, how would you rate your own health TODAY (out of 100 – 0 being the worst and 100 being Amazing!!):

0
i We adjusted the number you entered based on the slider’s scale.

* 9. How long have you been a client of Sherbourne Health Centre:  ________

* 10. How many times did you visit us over the last year or so for medical care?

* 11.  Would you recommend our services to your family or friends? (Check 1 only)

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