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Medical Home Survey - Middleboro Pediatrics
1.
My child's primary care provider(PCP) has asked me to share with him/her my knowledge and expertise as the parent or caregiver of a child with special healthcare needs.
Yes
No
2.
My child's PCP has asked me how my child's condition affects our entire family.
Yes
No
3.
My child's PCP understands how my child's medical, behavioral, or other conditions affect his/her day-to-day life.
Yes
No
4.
The office staff/nursing staff understands how my child's medical behavioral, or other conditions affect his/her experience in the office.
Yes
No
Please Comment:
5.
My PCP and/or care coordinator:
Yes
No
a. Help develop a healthcare plan for my child.
Yes
No
b. Use a care plan to help follow my child's progress.
Yes
No
c. Review and update the care plan with me regularly.
Yes
No
Please Comment:
6.
In the last 12 months, how much of a problem was it to get rehabilitation/therapeutic services or medical equipment for your child?
1 = somewhat difficult
2 = very difficult
3 = unable to obtain
Please Comment:
7.
What does your child need that you are not currently receiving?
8.
Are you interested in participating in a parent support group relevant to your child's medical/behavioral/emotional condition?
Yes
No
9.
Please add any further comments below that would be valuable feedback for improving your child's care and experience in our office.
10.
(Optional) Please provide your child's name in the box below.