CAHPS® 12 Month Survey 2.0 (Adult) Template Pouru Bhiwandi MD FACOG Gynecology Question Title * 1. Our records show that you got care from Dr. Bhiwandi. Is that right? Yes No Question Title * 2. How long have you been going to Dr. Bhiwandi? Less than 6 months At least 6 months but less than 1 year At least 1 year but less than 3 years At least 3 years but less than 5 years 5 years or more Question Title * 3. In the last 12 months, how many times did you visit Dr. Bhiwandi? None 1 time 2 3 4 5 to 9 10 or more times Question Title * 4. In the last 12 months, did you phone Dr. Bhiwandi’s office to get an appointment for an illness, injury, or condition that needed care right away? Yes No Question Title * 5. In the last 12 months, when you phoned Dr. Bhiwandi’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 NA Question Title * 6. In the last 12 months, did you make any appointments for a check-up or routine care with Dr. Bhiwandi? Yes No Question Title * 7. In the last 12 months, when you made an appointment for a check-up or routine care with Dr. Bhiwandi, how often did you get an appointment as soon as you needed? Never Sometimes Usually Always NA Question Title * 8. In the last 12 months, did you phone Dr. Bhiwandi’s office with a medical question during regular office hours? Yes No Question Title * 9. In the last 12 months, when you phoned Dr. Bhiwandi’s office during regular office hours, how often did you get an answer to your medical question that same day? Never Sometimes Usually Always NA Question Title * 10. In the last 12 months, did you phone Dr. Bhiwandi’s office with a medical question after regular office hours? Yes No Question Title * 11. In the last 12 months, when you phoned Dr. Bhiwandi’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 NA Question Title * 12. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see Dr. Bhiwandi within 15 minutes of your appointment time? Never Sometimes Usually Always NA Question Title * 13. In the last 12 months, how often did Dr. Bhiwandi explain things in a way that was easy to understand? Never Sometimes Usually Always NA Question Title * 14. In the last 12 months, how often did Dr. Bhiwandi listen carefully to you? Never Sometimes Usually Always NA Question Title * 15. In the last 12 months, how often did Dr. Bhiwandi give you easy to understand information about these health questions or concerns? Never Sometimes Usually Always NA Question Title * 16. In the last 12 months, how often did Dr. Bhiwandi seem to know the important information about your medical history? Never Sometimes Usually Always NA Question Title * 17. In the last 12 months, how often did Dr. Bhiwandi show respect for what you had to say? Never Sometimes Usually Always NA Question Title * 18. In the last 12 months, how often did Dr. Bhiwandi spend enough time with you? Never Sometimes Usually Always NA Question Title * 19. In the last 12 months, did Dr. Bhiwandi order a blood test, x-ray, or other test for you? Yes No Question Title * 20. In the last 12 months, when Dr. Bhiwandi ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results? Never Sometimes Usually Always NA 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 Dr. Bhiwandi? 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 Question Title * 22. In the last 12 months, how often were clerks and receptionists at Dr. Bhiwandi's office as helpful as you thought they should be? Never Sometimes Usually Always NA Question Title * 23. In the last 12 months, how often did clerks and receptionists at Dr. Bhiwandi's office treat you with courtesy and respect? Never Sometimes Usually Always NA Question Title * 24. In general, how would you rate your overall health? Excellent Very good Good Fair Poor Question Title * 25. In general, how would you rate your overall mental or emotional health? Excellent Very good Good Fair Poor 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 Question Title * 27. Did someone help you complete this survey? Yes No Question Title * 28. 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 Helped in some other way Done