Chesley, Durham, Mildmay, Paisley and Walkerton Sites

BROCKTON & AREA FAMILY HEALTH TEAM
PATIENT EXPERIENCE SURVEY

You are being invited to take part in this survey because you have recently had a visit at the Brockton & Area Family Health Team. Your responses to the questions on this survey will help us improve the care we provide.

Participation in the survey is completely voluntary and all your responses to the survey questions will be kept confidential.

PART 1

QUESTIONS CONCERNING YOUR FAMILY PHYSICIAN

Question Title

* Please select the location of the medical clinic where you receive services:

Question Title

* Please select the name of your Family Physician:

Question Title

* The last time you were sick or were concerned you had a health problem, did you get an appointment with your physician on the date you wanted?

Yes

Question Title

* The last time you were sick or were concerned you had a health problem, how many days did it take from when you first tried to see your physician to when you actually saw him/her, or someone else in the office?

Same day

Next day

2-19 days (please enter # of days in comment section)

20 or more days

Not applicable (don't know/refused)

# of days

Question Title

* When you see your physician, how often does he/she, or someone else in the office give you an opportunity to ask questions about recommended treatment?

Never

Rarely

Sometimes

Often

Always

Question Title

* When you see your physician, how often does he/she, or someone else in the office involve you as much as you want to be in decisions about your care and treatment?

Never

Rarely

Sometimes

Often

Always

Question Title

* When you see your physician, how often does he/she, or someone else in the office spend enough time with you?

Never

Rarely

Sometimes

Often

Always

Question Title

* Please rate your overall satisfaction with the service at your physician's office:

Very Poor

Poor

Neutral

Good

Excellent

PART 2

QUESTIONS CONCERNING YOUR APPOINTMENT WITH YOUR FAMILY HEALTH TEAM MEMBER

Question Title

*
Please select the name of the Family Health Team Member you last saw:

Question Title

* Did you get an appointment on the date you wanted with this provider?

Yes

Question Title

* How many days did it take from when you first tried, or were contacted, to see your Family Health Team member to when you actually saw him/her?

Same day

Next day

2-19 days (Enter # of days below)

20 or more days

Not applicable (don't know, refused)

# of days:

Question Title

* When you see your Family Health Team Member, how often does he/she give you an opportunity to ask questions about recommended treatment?

Never

Rarely

Sometimes

Often

Always

Question Title

* When you see your Family Health Team Member, how often does he/she involve you as much as you want to be in decisions about your care and treatment?

Never

Rarely

Sometimes

Often

Always

Question Title

* When you see your Family Health Team Member, how often does he/she spend enough time with you?

Never

Rarely

Sometimes

Often

Always

Question Title

* Please rate your overall satisfaction with the service at your Family Health Team:

Very Poor

Poor

Neutral

Good

Excellent

Question Title

* Please select the location of the medical clinic where you receive services:

Question Title

* Please select the name of your Family Physician:

Question Title

* The last time you were sick or were concerned you had a health problem, did you get an appointment with your physician on the date you wanted?

Question Title

* The last time you were sick or were concerned you had a health problem, how many days did it take from when you first tried to see your physician to when you actually saw him/her, or someone else in the office?

Question Title

* When you see your physician, how often does he/she, or someone else in the office give you an opportunity to ask questions about recommended treatment?

Question Title

* When you see your physician, how often does he/she, or someone else in the office involve you as much as you want to be in decisions about your care and treatment?

Question Title

* When you see your physician, how often does he/she, or someone else in the office spend enough time with you?

Question Title

* Please rate your overall satisfaction with the service at your physician's office:

Question Title

* Please select the name of the Family Health Team Member you last saw:

Question Title

* Did you get an appointment on the date you wanted with this provider?

Question Title

* How many days did it take from when you first tried, or were contacted, to see your Family Health Team member to when you actually saw him/her?

Question Title

* When you see your Family Health Team Member, how often does he/she give you an opportunity to ask questions about recommended treatment?

Question Title

* When you see your Family Health Team Member, how often does he/she involve you as much as you want to be in decisions about your care and treatment?

Question Title

* When you see your Family Health Team Member, how often does he/she spend enough time with you?

Question Title

* Please rate your overall satisfaction with the service at your Family Health Team:

Question Title

* Is there any additional information or feedback you would like to share with us that could help us to improve the way we provide care?

*
Please select the name of the Family Health Team Member you last saw: