CAHPS® Visit Survey 2.0 Template FAYETTEVILLE WOMAN'S CARE PATIENT SATISFACTION SURVEY Question Title * 1. Our records show that you got care from Fayetteville Woman's Care. Is that right? Yes No Question Title * 2. At which location was your visit? Fayetteville Lumberton Question Title * 3. Who did you see at your most recent visit? Strickland Davis Wood Rodriguez Glass Ferrell Booth Question Title * 4. How long have you been going to Fayetteville Woman's Care? 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 * 5. In the last 12 months, did you phone Fayetteville Woman's Care’s office to get an appointment for an illness, injury, or condition that needed care right away? Yes No Question Title * 6. In the last 12 months, when you phoned Fayetteville Woman's Care’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed? Never Sometimes Usually Always NA Question Title * 7. In the last 12 months, when you made an appointment for a check-up or routine care with Fayetteville Woman's Care, how often did you get an appointment as soon as you needed? Never Sometimes Usually Always Question Title * 8. In the last 12 months, did you phone Fayetteville Woman's Care’s office with a medical question during regular office hours? Yes No NA Question Title * 9. In the last 12 months, when you phoned Fayetteville Woman's Care’s office during regular office hours, how often did you get an answer to your medical question that same day? Never Sometimes Usually Always NA Question Title * 10. In the last 12 months, when you contacted Fayetteville Woman's Care’s office with a medical question during regular office hours, did you interact with the Triage Nurse? Yes No NA Question Title * 11. In the last 12 months, when you interacted with the Triage Nurse, how would rate your experience? Poor to Very Poor Fair Neutral Good Very Good to Exceptional NA Comment Question Title * 12. In the last 12 months, have you phoned Fayetteville Woman's Care’s office with a medical question after regular office hours? Yes No Question Title * 13. In the last 12 months, when you phoned Fayetteville Woman's Care’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed? Never Sometimes Usually Always NA Question Title * 14. How long has it been since your most recent visit with Fayetteville Woman's Care? Less than 1 month At least 1 month but less than 3 months At least 3 months but less than 6 months At least 6 months but less than 12 months 12 months or more Question Title * 15. During your most recent visit, did your healthcare provider explain things in a way that was easy to understand? Yes, definitely Yes, somewhat No Question Title * 16. During your most recent visit, did your healthcare provider listen carefully to you? Yes, definitely Yes, somewhat No Question Title * 17. During your most recent visit, did your healthcare provider seem to know the important information about your medical history? Yes, definitely Yes, somewhat No Question Title * 18. During your most recent visit, did your healthcare provider show respect for what you had to say? Yes, definitely Yes, somewhat No Question Title * 19. During your most recent visit, did your healthcare provider spend enough time with you? Yes, definitely Yes, somewhat No Question Title * 20. During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you? Yes No Question Title * 21. Did someone from your healthcare provider’s office follow up to give you any abnormal results? Yes No NA Question Title * 22. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best experience possible, what number would you use to rate Fayetteville Woman's Care's coordination of any referrals you required? 10 Best experience possible 9 8 7 6 5 4 3 2 1 0 Worst experience possible N/A . . 10 Best experience possible . 9 . 8 . 7 . 6 . 5 . 4 . 3 . 2 . 1 . 0 Worst experience possible . N/A Question Title * 23. 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 your healthcare provider? 10 Best provider possible 9 8 7 6 5 4 3 2 1 0 Worst provider possible . . 10 Best provider possible . 9 . 8 . 7 . 6 . 5 . 4 . 3 . 2 . 1 . 0 Worst provider possible Question Title * 24. Have you used the Patient Portal to send a message to the office or clinical staff? Yes No Question Title * 25. Have you used the Patient Portal to review your medical information or lab results? Yes No Question Title * 26. Have you used the Patient Portal to request a medication or medication refill? Yes No Question Title * 27. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, how do you rate the Patient Portal for ease of use? 10 Very Easy 9 8 7 6 5 4 3 2 1 0 Very Difficult . . 10 Very Easy . 9 . 8 . 7 . 6 . 5 . 4 . 3 . 2 . 1 . 0 Very Difficult Question Title * 28. Would you recommend Fayetteville Woman's Care’s office to your family and friends? Yes, definitely Yes, somewhat No Question Title * 29. During your most recent visit, did clerks and receptionists at Fayetteville Woman's Care’s office treat you with courtesy and respect? Yes, definitely Yes, somewhat No Question Title * 30. 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 * 31. 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 * 32. Are you of Hispanic or Latino origin or descent? Yes, Hispanic or Latino No, not Hispanic or Latino Question Title * 33. What is your race? Mark one or more. White Black or African American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other Question Title * 34. Do you have any other comments, questions, or concerns? Done
