Question Title

* 1. Our records show that you got care from your healthcare provider. Is that right?

Question Title

* 2. Is your healthcare provider, the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

Question Title

* 3. How long have you been going to your healthcare provider?

Question Title

* 4. In the last 12 months, how many times did you visit your healthcare provider?

Question Title

* 5. In the last 12 months, did you phone your healthcare provider’s office to get an appointment for an illness, injury, or condition that needed care right away?

Question Title

* 6. In the last 12 months, when you phoned your healthcare provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

Question Title

* 7. In the last 12 months, did you make any appointments for a check-up or routine care with your healthcare provider?

Question Title

* 8. In the last 12 months, when you made an appointment for a check-up or routine care with your healthcare provider, how often did you get an appointment as soon as you needed?

Question Title

* 9. In the last 12 months, did you phone your healthcare provider’s office with a medical question during regular office hours?

Question Title

* 10. In the last 12 months, when you phoned your healthcare provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

Question Title

* 11. In the last 12 months, did you phone your healthcare provider’s office with a medical question after regular office hours?

Question Title

* 12. In the last 12 months, when you phoned your healthcare provider’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?

Question Title

* 13. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see your healthcare provider within 15 minutes of your appointment time?

Question Title

* 14. How long has it been since your most recent visit with your healthcare provider?

Question Title

* 15. Wait time includes time spent in the waiting room and exam room. During your most recent visit, did you see your healthcare provider within 15 minutes of your appointment time?

Question Title

* 16. During your most recent visit, did your healthcare provider explain things in a way that was easy to understand?

Question Title

* 17. During your most recent visit, did your healthcare provider listen carefully to you?

Question Title

* 18. During your most recent visit, did you talk with your healthcare provider about any health questions or concerns?

Question Title

* 19. During your most recent visit, did your healthcare provider give you easy to understand information about these health questions or concerns?

Question Title

* 20. During your most recent visit, did your healthcare provider seem to know the important information about your medical history?

Question Title

* 21. During your most recent visit, did your healthcare provider show respect for what you had to say?

Question Title

* 22. During your most recent visit, did your healthcare provider spend enough time with you?

Question Title

* 23. During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you?

Question Title

* 24. Did someone from your healthcare provider’s office follow up to give you those results?

Question Title

* 25. 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
.

Question Title

* 26. Would you recommend your healthcare provider’s office to your family and friends?

Question Title

* 27. During your most recent visit, were clerks and receptionists at your healthcare provider’s office as helpful as you thought they should be?

Question Title

* 28. During your most recent visit, did clerks and receptionists at your healthcare provider’s office treat you with courtesy and respect?

Question Title

* 29. In general, how would you rate your overall health?

Question Title

* 30. In general, how would you rate your overall mental or emotional health?

Question Title

* 31. What is your age?

Question Title

* 32. Are you male or female?

Question Title

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

Question Title

* 34. Are you of Hispanic or Latino origin or descent?

Question Title

* 35. What is your race? Mark one or more.

Question Title

* 36. Did someone help you complete this survey?

Question Title

* 37. How did that person help you? Mark one or more.

T