* 1. Our records show that your child got care from one of our healthcare provider's. Please choose the provider that you received care from.

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

* 3. How long have  you been coming to a healthcare provider at our office?

* 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? (If no go to # 7)

* 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?

* 6. In the last 12 months, did you make any appointments for a check up or routine care with your healthcare provider? (If no go to #9)

* 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?

* 8. In the last 12 months, when you phoned or messaged the triage nurse during regular office hours, how often did you get an answer to your medical question that same day?

* 9. In the last 12 months, when you phoned the after hours provider on call , did you get an answer to your medical question as soon as you needed?

* 10. 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 30 minutes of your appointment time for a sick visit?

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

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

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

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

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

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

* 17. 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
.

* 18. Would you recommend our office to your family and friends?

* 19. During your most recent visit, were the receptionists as helpful as you thought they should be?

* 20. During your most recent visit, did nurses and medical assistant's  treat you with courtesy and respect?

* 21. During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you?  If no skip to question #23.

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

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

* 24. In the last 12 months has your healthcare provider referred you to a
specialist? If no skip to question # 25

* 25. Did someone from your healthcare provider's office assist you in
coordinating/scheduling  your referral appointment?

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

* 27. In general, how would you rate your child's overall health?

* 28. In general, how would you rate your child's overall mental or emotional health?

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

* 30. Is your child of Hispanic or Latino origin or descent?

* 31. Is  your child male or female?

* 32. What is your child's race? Mark one or more.

* 33. Is the healthcare provider you saw, the provider you usually see if you need a physical, want advice about a health problem, or get sick or hurt?

* 34. Did someone help you complete this survey?

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

* 36. Please leave comments , suggestions or concerns. Thank you!

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