Community Health Service Agency, Inc.... Your Medical Home.

Patient Experience Questions

Please complete the survey about your most recent visit to a CHSA health center. Thank you for your participation.

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* 1. Is the appointment you are reviewing today within the last -

Week

Month

Several months

Year

More than a year

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* 2. When you called to schedule an appointment to be seen right away, when were you seen?

Same day

1 day

2 to 3 days

4 to 7 days

More than 7 days

Don't know, no answer

Other (please specify)

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* 3. How often did this provider explain things in a way that was easy to understand?

Never

Sometimes

Usually

Always

Don't know, no answer

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* 4. Did anyone in this provider's office talk with you about specific goals for your health?

Yes

Don't know, no answer

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* 5. Did you see a specialist for a particular health problem? Specialists are doctors like surgeons, heart doctors, OB-GYNs, allergy doctors, skin doctors, and other doctors who specialize in one area of health care.

Yes

No, If no- skip the next question--

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* 6. How often did your provider seem informed and up-to-date about the care you got from the specialists?

Never

Sometimes

Usually

Always

Don't know, no answer

Not applicable

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* 7. Would you recommend this health center to someone else?

Yes

Please describe why:

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* 8. How did you hear about the health center?

A relative or friend

Flyer or other printed materials

Announcements on the radio or television

School

Church

Social Media (e.g. Facebook)

None of the above, I came here because I knew the provider was at this location

Don't know, no answer

Or another source

If you answered another source please describe:

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* 9. How was your experience when you called your health center? (1 being the worst and 10 being the best)

To help improve your experience, please describe why you chose your rating.

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* 10. Do you consider yourself White, Black or African American, Hispanic or Latino, Asian or some other race-ethnic group?

White or Caucasian

Black or African American

Hispanic or Latino

Asian

Refused

Other race- ethnic group

If you answered other race- ethnic group, please describe:

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* 11. Indicate below your Primary Care Provider (PCP) at your health center. If you cannot remember your PCP's name, please list the location where you were seen.

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* 1. Is the appointment you are reviewing today within the last -

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* 2. When you called to schedule an appointment to be seen right away, when were you seen?

Question Title

* 3. How often did this provider explain things in a way that was easy to understand?

Question Title

* 4. Did anyone in this provider's office talk with you about specific goals for your health?

Question Title

* 5. Did you see a specialist for a particular health problem? Specialists are doctors like surgeons, heart doctors, OB-GYNs, allergy doctors, skin doctors, and other doctors who specialize in one area of health care.

Question Title

* 6. How often did your provider seem informed and up-to-date about the care you got from the specialists?

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* 7. Would you recommend this health center to someone else?

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* 8. How did you hear about the health center?

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* 9. How was your experience when you called your health center? (1 being the worst and 10 being the best)

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* 10. Do you consider yourself White, Black or African American, Hispanic or Latino, Asian or some other race-ethnic group?

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* 11. Indicate below your Primary Care Provider (PCP) at your health center. If you cannot remember your PCP's name, please list the location where you were seen.

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* 12. Any other comments you would like to share about the health center?