* 1. How long have you been going to Samantha Cole?

* 2. How well did your provider listen to your needs?

* 3. How well did your provider answer your questions?

* 4. 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 Samantha Cole?

  10 Best provider possible 9 8 7 6 5 4 3 2 1 0 Worst provider possible
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* 5. 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?

* 6. In general, how would you rate your overall mental or emotional health?

* 7. In the last 12 months, how often did Samantha Cole explain things in a way that was easy to understand?

* 8. Would you recommend Samantha Cole’s office to your family and friends?

* 9. Do you have any other comments, questions, or concerns?

* 10. Are you male or female?

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