We Want To Hear From You!

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* 1. Which provider did you see today?

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* 2. What location was your appointment?

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* 3. Today's Date

Date 

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* 4. Day of Service

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* 5. Are you a new patient or an established patient?

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* 6. What is your age?

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* 7. Sex

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* 8. Race/Ethnicity

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* 9. Hispanic or Latino origin/descent

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* 10. Ease of Getting Care

  Great Good OK Fair Poor
Ability to get in to be seen
Hours center is open
Prompt return on calls

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* 11. Waiting

  Great Good Ok Fair Poor
Waiting to see provider
Waiting for tests to be performed
Waiting for test results
Wait for referral appointments

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* 12. Your provider (MDs, PAs, NPs, etc.)

  Great Good Ok Fair Poor
Listens to you
Takes enough time with you
Explains what you want to know
Gives you good advice and treatment

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* 13. Staff (Nurses, Medical Assistants, Office Staff, etc,)

  Great Good Ok Fair Poor
Friendly and helpful to you
Answers your questions

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* 14. Confidentiality

  Great Good Ok Fair Poor
Keeping my personal information private

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* 15. About You

  Great Good Ok Fair Poor
In general, how would you rate your overall health?
In general, how would you rate your overall mental or emotional health?

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* 16. Do you consider this your regular or primary source of care?

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

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* 18. Did someone help you complete this survey?

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* 19. How did someone help you with completing this survey (check all that apply)?

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* 20. Additional Comments

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* 21. If you would like someone to follow-up on your comments please provide additional information.

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