* 1. 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?

* 2. In the last 12 months, how many times did you visit Centre Ob/Gyn?

* 3. In the last 12 months, did you phone Centre Ob/Gyn’s office to get an appointment for an illness, injury, or condition that needed care right away?

* 4. In the last 12 months, when you phoned Centre Ob/Gyn’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

* 5. In the last 12 months, did you make any appointments for a check-up or routine care with Centre Ob/Gyn?

* 6. In the last 12 months, when you made an appointment for a check-up or routine care with your healthcare provider, how often did you get an appointment as soon as you needed?

* 7. In the last 12 months, did you phone Centre Ob/Gyn’s office with a medical question during regular office hours?

* 8. In the last 12 months, when you phoned Centre Ob/Gyn’s office during regular office hours, how often did you get an answer to your medical question that same day?

* 9. In the last 12 months, did you phone Centre Ob/Gyn’s office with a medical question after regular office hours?

* 10. In the last 12 months, when you phoned Centre Ob/Gyn’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?

* 11. 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?

* 12. During your most recent visit, did your healthcare provider explain things in a way that was easy to understand?

* 13. During your most recent visit, did your healthcare provider listen carefully to you?

* 14. During your most recent visit, did you talk with your healthcare provider about any health questions or concerns?

* 15. During your most recent visit, did your healthcare provider give you easy to understand information about these health questions or concerns?

* 16. During your most recent visit, did your healthcare provider seem to know the important information about your medical history?

* 17. During your most recent visit, did your healthcare provider show respect for what you had to say?

* 18. During your most recent visit, did your healthcare provider spend enough time with you?

* 19. During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you?

* 20. Did someone from your healthcare provider’s office follow up to give you those results?

* 21. 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
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* 22. Would you recommend Centre Ob/Gyn’s office to your family and friends?

* 23. During your most recent visit, were clerks and receptionists at Centre Ob/Gyn’s office as helpful as you thought they should be?

* 24. During your most recent visit, did clerks and receptionists at Centre Ob/Gyn’s office treat you with courtesy and respect?

* 25. In general, how would you rate your overall health?

* 26. What is your age?

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

* 28. Did someone help you complete this survey?

* 29. How did that person help you? Mark one or more.

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