CAHPS® 12 Month Survey 2.0 (Adult) Template

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* 1. Who is your usual healthcare provider

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* 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?

Yes

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

None

1 time

5 to 9

10 or more times

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* 4. 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?

Yes

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* 5. 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?

Never

Sometimes

Usually

Always

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

Yes

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* 7. 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?

Never

Sometimes

Usually

Always

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

Yes

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* 9. 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?

Never

Sometimes

Usually

Always

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

Yes

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* 11. 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?

Never

Sometimes

Usually

Always

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* 12. 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?

Never

Sometimes

Usually

Always

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* 13. In the last 12 months, how often did your healthcare provider explain things in a way that was easy to understand?

Never

Sometimes

Usually

Always

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* 14. In the last 12 months, how often did your healthcare provider listen carefully to you?

Never

Sometimes

Usually

Always

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* 15. In the last 12 months, how often did your healthcare provider give you easy to understand information about these health questions or concerns?

Never

Sometimes

Usually

Always

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* 16. In the last 12 months, how often did your healthcare provider seem to know the important information about your medical history?

Never

Sometimes

Usually

Always

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* 17. In the last 12 months, how often did your healthcare provider show respect for what you had to say?

Never

Sometimes

Usually

Always

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* 18. In the last 12 months, how often did your healthcare provider spend enough time with you?

Never

Sometimes

Usually

Always

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* 19. In the last 12 months, did your healthcare provider order a blood test, x-ray, or other test for you?

Yes

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* 20. In the last 12 months, when your healthcare 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

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* 21. 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

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* 22. In the last 12 months, how often were clerks and receptionists at your healthcare provider's office as helpful as you thought they should be?

Never

Sometimes

Usually

Always

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* 23. In the last 12 months, how often did clerks and receptionists at your healthcare provider's office treat you with courtesy and respect?

Never

Sometimes

Usually

Always

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

Excellent

Very good

Good

Fair

Poor

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

Excellent

Very good

Good

Fair

Poor

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* 26. 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

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* 27. Are you male or female?

Male

Female

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* 28. 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

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

Yes, Hispanic or Latino

No, not Hispanic or Latino

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* 30. 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

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* 31. Did someone help you complete this survey?

Yes

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* 32. 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

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* 33. Have you ever been given information on what it means to have a "medical home" ?

Yes

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* 34. Do you feel that we are your medical home?

Yes

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* 35. Did someone talk to you today about your health goals?

Yes

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* 36. Are you aware of our sliding fee scale program?

Yes

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* 37. Triad Adult and Pediatric Medicine's nominal fee is $20. Has this fee prevented you from accessing services or created a barrier to receiving services here?

Yes

If yes why:

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* 38. Nominal charges allow patients to participate in supporting the cost of their care. What amount would you suggest as a nominal fee?

$15

$20

$25

other