* 1. Who do you see today?

* 2. In what year were you born? (enter 4-digit birth year; for example, 1976)

* 3. Please select your gender.

* 4. I was able to schedule an appointment on the day on the day I wanted.

* 5. I made a list of my concerns before the visit with my care team.

* 6. My clinician asked my thoughts on the treatment goals to which we agreed.

* 7. My questions were answered in a way that I could understand.

* 8. I was satisfied with the amount of time I spent with my clinician.

* 9. I was able to see the clinician I requested.

* 10. My clinician is concerned about me as a person, not just my illness.

* 11. My care team contacts me to remind me I need to come in for my checkup.

* 12. I know my rights and responsibilities as a patient at this practice.

* 13. I am at ease asking questions about my healthcare concerns.

* 14. My clinician is a good listener.

* 15. I can manage my health better because of what I learn from my clinician and the care team.

* 16. My clinician tells me the common side effects for each of my treatment choices.

* 17. I have a say in decisions about my care.

* 18. I am notified in a timely manner of test results after I have had lab work and xrays.

* 19. I am asked about my satisfaction with my healthcare.

* 20. When I have questions about my bill, my questionsare answered politely.

* 21. The practice makes information available to me through their website.

* 22. I can easily get in touch with the practice after regular hours and on weekends.

* 23. I would refer my family and friends to this practice.

* 24. What do you like about the practice?

* 25. What would you improve about the practice?

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