CAHPS® Visit Survey 2.0 Template Central Carolina Obstetrics and Gynecology Patient Survey Question Title * 1. Our records show that you got care from your healthcare provider. Is that right? Yes No Question Title * 2. How long have you been going to your healthcare provider? Less than 6 months At least 6 months but less than 1 year At least 1 year but less than 3 years At least 3 years but less than 5 years 5 years or more Question Title * 3. In the last 12 months, did you phone your healthcare provider’s office to get an appointment for an illness, injury, or condition that needed care right away? Yes No Question Title * 4. In the last 12 months, when you phoned your healthcare provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed? Never Sometimes Usually Always Question Title * 5. In the last 12 months, did you phone your healthcare provider’s office with a medical question during regular office hours? Yes No Question Title * 6. In the last 12 months, when you phoned your healthcare provider’s office during regular office hours, how often did you get an answer to your medical question that same day? Never Sometimes Usually Always Question Title * 7. In the last 12 months, did you phone your healthcare provider’s office with a medical question after regular office hours? Yes No Question Title * 8. In the last 12 months, when you phoned your healthcare provider’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed? Never Sometimes Usually Always Question Title * 9. Wait time includes time spent in the waiting room and exam room. During your most recent visit, did you see your healthcare provider within 15 minutes of your appointment time? Yes No Question Title * 10. During your most recent visit, did staff members at your healthcare provider’s office treat you with courtesy and respect? Yes, definitely Yes, somewhat No Question Title * 11. During your most recent visit, did you talk with your healthcare provider about any health questions or concerns? Yes No Question Title * 12. During your most recent visit, did your healthcare provider listen carefully to you? Yes, definitely Yes, somewhat No Question Title * 13. During your most recent visit, did your healthcare provider seem to know the important information about your medical history? Yes, definitely Yes, somewhat No Question Title * 14. During your most recent visit, did your healthcare provider spend enough time with you? Yes, definitely Yes, somewhat No Question Title * 15. Is your healthcare provider the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt? Yes No Question Title * 16. During your most recent visit, did your healthcare provider explain things in a way that was easy to understand? Yes, definitely Yes, somewhat No Question Title * 17. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate your healthcare provider? 10 Best provider possible 9 8 7 6 5 4 3 2 1 0 Worst provider possible . . 10 Best provider possible . 9 . 8 . 7 . 6 . 5 . 4 . 3 . 2 . 1 . 0 Worst provider possible Question Title * 18. Would you recommend your healthcare provider’s office to your family and friends? Yes, definitely Yes, somewhat No Question Title * 19. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older Question Title * 20. Do you have any other comments, questions, or concerns? Done