CAHPS® Visit Survey 2.0 Template-2017 Question Title * 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? Yes No OK Question Title * 2. In the last 12 months, how many times did you visit Centre Ob/Gyn? None 1 time 2 3 4 5 to 9 10 or more times OK Question Title * 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? Yes No OK Question Title * 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? Never Sometimes Usually Always Not Applicable OK Question Title * 5. In the last 12 months, did you make any appointments for a check-up or routine care with Centre Ob/Gyn? Yes No OK Question Title * 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? Never Sometimes Usually Always Not Applicable OK Question Title * 7. In the last 12 months, did you phone Centre Ob/Gyn’s office with a medical question during regular office hours? Yes No OK Question Title * 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? Never Sometimes Usually Always OK Question Title * 9. In the last 12 months, did you phone Centre Ob/Gyn’s office with a medical question after regular office hours? Yes No OK Question Title * 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? Never Sometimes Usually Always Not Applicable OK Question Title * 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? Yes No OK Question Title * 12. During your most recent visit, did your healthcare provider explain things in a way that was easy to understand? Yes, definitely Yes, somewhat No OK Question Title * 13. During your most recent visit, did your healthcare provider listen carefully to you? Yes, definitely Yes, somewhat No OK Question Title * 14. During your most recent visit, did you talk with your healthcare provider about any health questions or concerns? Yes No OK Question Title * 15. During your most recent visit, did your healthcare provider give you easy to understand information about these health questions or concerns? Yes, definitely Yes, somewhat No Not Applicable OK Question Title * 16. During your most recent visit, did your healthcare provider seem to know the important information about your medical history? Yes, definitely Yes, somewhat No OK Question Title * 17. During your most recent visit, did your healthcare provider show respect for what you had to say? Yes, definitely Yes, somewhat No OK Question Title * 18. During your most recent visit, did your healthcare provider spend enough time with you? Yes, definitely Yes, somewhat No OK Question Title * 19. During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you? Yes No Not Applicable OK Question Title * 20. Did someone from your healthcare provider’s office follow up to give you those results? Yes No Not Applicable OK Question Title * 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 . . 10 Best provider possible . 9 . 8 . 7 . 6 . 5 . 4 . 3 . 2 . 1 . 0 Worst provider possible OK Question Title * 22. Would you recommend Centre Ob/Gyn’s office to your family and friends? Yes, definitely Yes, somewhat No Other (please specify) OK Question Title * 23. During your most recent visit, were clerks and receptionists at Centre Ob/Gyn’s office as helpful as you thought they should be? Yes, definitely Yes, somewhat No OK Question Title * 24. During your most recent visit, did clerks and receptionists at Centre Ob/Gyn’s office treat you with courtesy and respect? Yes, definitely Yes, somewhat No OK Question Title * 25. In general, how would you rate your overall health? Excellent Very good Good Fair Poor OK Question Title * 26. 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 OK Question Title * 27. What is the highest grade or level of school that you have completed? 8th grade or less Some high school, but did not graduate High school graduate or GED Some college or 2-year degree 4-year college graduate More than 4-year college degree OK Question Title * 28. Did someone help you complete this survey? Yes No OK Question Title * 29. How did that person help you? Mark one or more. Read the questions to me Wrote down the answers I gave Answered the questions for me Translated the questions into my language Not Applicable OK DONE