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* 1. How long have you been a patient at Atrium ObGyn?

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* 2. Which provider did you see at your most recent visit?

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* 3. The next 12 questions apply to your MOST RECENT VISIT ONLY.
Wait time includes time spent in the waiting room and exam room. Did you see your healthcare provider within 20 minutes of your appointment time?

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* 4. Did your healthcare provider listen carefully to you?

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* 5. Did your healthcare provider explain things in a way that was easy to understand?

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* 6. Did your healthcare provider seem to know the important information about your medical history?

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* 7. Did you talk with your healthcare provider about any health questions or concerns?

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* 8. Did your healthcare provider give you easy to understand information about these health questions or concerns?

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* 9. Did your healthcare provider spend enough time with you?

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* 10. Did your healthcare provider show respect for what you had to say?

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* 11. Did your healthcare provider order a blood test, x-ray, or other test for you?

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* 12. Did someone from our office follow up to give you those results?

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* 13. Using any number from 0 to 5, where 0 is the worst provider possible and 5 is the best provider possible, what number would you use to rate your healthcare provider?

  5 Best Provider Possible 4 3 2 1 0 Worst Provider Possible
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* 14. Did receptionists and administrative staff treat you with dignity and respect and were they as helpful as you thought they should be?

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* 15. Did clinical staff treat you with courtesy and respect and were they as helpful as you thought they should be?

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* 16. In the last 12 months, when you phoned our office with a medical question AFTER regular office hours, how often did you get an answer to your medical question as soon as you needed?

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

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* 18. In the last 12 months, when you phoned our office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

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

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

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

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

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* 23. Would you recommend Atrium ObGyn to your family and friends?

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* 24. Do you have any other comments, questions or concerns?

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

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* 26. What is your age?

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