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2026 CCH&WC - Patient Satisfaction Survey
1.
What clinic location are you submitting this evaluation for?
North Clinic - Roseburg Edenbower Location
South Clinic - Canyonville Wartahoo Location
Other (please specify)
2.
What is your gender?
Female
Male
Non-binary / Third Gender
Prefer not to say
Other (specify)
3.
What is your age?
Under 18
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
4.
What is your race and/or ethnicity? (Select all that apply)
Black or African American
Hispanic or Latino/a/x
American Indian or Alaska Native
Asian
White
Native Hawaiian or Pacific Islander
Other (please specify)
5.
How did you hear about our office?
Referring provider
Friend / Word of Mouth
Social Media
Employee
Internet
Employee
Insurance Recommendation / Directory
Tribal Recommendation
Hospital Recommendation
Television / Newspaper
Community Event / Health Fair
Other (please specify)
6.
Which provider were you scheduled with/for today?
Dr. Lorrie Oksenholt (Roseburg)
Dr. Julie vanPutten (Roseburg)
Ben Jeppe, FNP (Roseburg)
Michelle Phelps, FNP (Roseburg)
Podiatry - Micah Tovey, DPM
Dr. Thomas Turk (Canyonville)
Kimberlly Stevens, FNP (Canyonville)
Jennie Schenk, FNP (Canyonville)
Massage - Valerie Reneau
Dr. April Gilliom
Claire Grubb, Dietician
Peyton Rondeau, Dietician
Lab Services (Roseburg)
Lab Services (Canyonville)
Other (please specify)
7.
How easy or difficult was it to schedule your appointment at a time that was convenient for you?
Very easy
Easy
Neither easy nor difficult
Difficult
Very difficult
8.
Were you offered an interpreter if you needed one? (Mark N/A if an interpreter isn't needed)
Yes
No
N/A
9.
Wait time includes time spent in the waiting room and exam room. During your most recent visit, how satisfied were you with the wait time before being seen by your provider?
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
10.
In the last 6 months, when you needed care right away, how often did you get care as soon as you needed?
Always
Usually
Sometimes
Never
11.
Did you feel safe and respected while discussing your sexual orientation or gender identity, if applicable?
Yes
No
N/A
12.
In the past 12 months, did anyone at your clinic ask if you had trouble accessing transportation, housing, or food?
Yes
No
N/A
13.
In the last 6 months, how often were front office staff at this provider’s office as helpful as you thought they should be?
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
14.
How would you rate the provider’s attentiveness and communication during your visit?
Excellent
Good
Fair
Poor
Excellent
Good
Fair
Poor
15.
Did your provider treat you with respect, regardless of your race, ethnicity, gender, sexual orientation, or background?
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
16.
In the last 6 months, how often did this provider seem to know the important information about your medical history?
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
17.
In the last 6 months, how often did you and someone from this provider’s office talk about all the prescription medicines you were taking?
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
18.
How effective do you feel the treatment or advice you received will be in managing your health concern?
Very Effective
Somewhat Effective
Neutral
Not Very Effective
Not at all Effective
Very Effective
Somewhat Effective
Neutral
Not Very Effective
Not at all Effective
19.
How satisfied are you with your overall experience at Cow Creek Health & Wellness Center?
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
20.
How would you rate the cleanliness of our office during your visit?
Excellent
Good
Fair
Poor
Excellent
Good
Fair
Poor
21.
How likely are you to recommend Cow Creek Health & Wellness Center to your family and friends?
Very Likely
Likely
Neutral
Unlikely
Very Unlikely
Very Likely
Likely
Neutral
Unlikely
Very Unlikely
22.
We appreciate your comments!
