CAHPS® 12 Month Survey 2.0 (Adult) Template Triad Adult and Pediatric Medicine Survey Question Title * 1. Who is your usual healthcare provider Danielle Artis, MD Teresa Bratton, MD Nykedtra Brown, FNP Peter Coccaro, MD Eric Dean, MD Michelle Edwards, NP Ramona Hayes, FNP Rachel Kime, NP Minda Kramer, NP Tanika Lewis, NP Sarrin List, NP Marcia Moran, MD Gretchen Netherton, NP Daphne Pierre Louis, FNP David Pitonzo, PA Athena Samaras, NP Andrea Scholer, MD Kawanna Skinner, NP Elizabeth Spangle, NP OK 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? Yes No OK Question Title * 3. In the last 12 months, how many times did you visit your healthcare provider? None 1 time 2 3 4 5 to 9 10 or more times OK Question Title * 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 No OK Question Title * 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 OK Question Title * 6. In the last 12 months, did you make any appointments for a check-up or routine care with your healthcare provider? Yes No OK Question Title * 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 OK Question Title * 8. In the last 12 months, did you phone your healthcare provider’s office with a medical question during regular office hours? Yes No OK Question Title * 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 OK Question Title * 10. In the last 12 months, did you phone your healthcare provider’s office with a medical question after regular office hours? Yes No OK Question Title * 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 OK Question Title * 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 OK Question Title * 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 OK Question Title * 14. In the last 12 months, how often did your healthcare provider listen carefully to you? Never Sometimes Usually Always OK Question Title * 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 OK Question Title * 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 OK Question Title * 17. In the last 12 months, how often did your healthcare provider show respect for what you had to say? Never Sometimes Usually Always OK Question Title * 18. In the last 12 months, how often did your healthcare provider spend enough time with you? Never Sometimes Usually Always OK Question Title * 19. In the last 12 months, did your healthcare provider order a blood test, x-ray, or other test for you? Yes No OK Question Title * 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 OK Question Title * 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 OK Question Title * 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 OK Question Title * 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 OK Question Title * 24. In general, how would you rate your overall health? Excellent Very good Good Fair Poor OK Question Title * 25. In general, how would you rate your overall mental or emotional health? Excellent Very good Good Fair Poor OK Question Title * 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 OK Question Title * 27. Are you male or female? Male Female OK Question Title * 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 OK Question Title * 29. Are you of Hispanic or Latino origin or descent? Yes, Hispanic or Latino No, not Hispanic or Latino OK Question Title * 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 OK Question Title * 31. Did someone help you complete this survey? Yes No OK Question Title * 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 OK Question Title * 33. Have you ever been given information on what it means to have a "medical home" ? Yes No OK Question Title * 34. Do you feel that we are your medical home? Yes No OK Question Title * 35. Did someone talk to you today about your health goals? Yes No OK Question Title * 36. Are you aware of our sliding fee scale program? Yes No OK Question Title * 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 No If yes why: OK Question Title * 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 OK DONE