Skip to content

CAHPS® 12 Month Survey 2.0 (Adult) Template

Durham Women's Clinic  - Patient Experience Survey Tool

1.Our records show that you got care from Durham Women's Clinic. Is that right?
2.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?
3.How long have you been going to your healthcare provider?
4.In the last 12 months, how many times did you visit your healthcare provider?
5.In the last 12 months, did you phone your healthcare provider’s office to get an appointment for an illness, injury, or condition that needed care right away?
6.In the last 12 months, when you phoned your healthcare provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
7.In the last 12 months, did you make any appointments for a check-up or routine care with your healthcare provider?
8.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?
9.In the last 12 months, did you phone your healthcare provider’s office with a medical question during regular office hours?
10.In the last 12 months, when you phoned your healthcare provider’s office during regular office hours, how often did you get an answer to your medical question that same day?
11.In the last 12 months, did you phone your healthcare provider’s office with a medical question after regular office hours?
12.In the last 12 months, when you phoned your healthcare provider’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?
13.Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see your healthcare provider within 15 minutes of your appointment time?
14.In the last 12 months, how often did your healthcare provider explain things in a way that was easy to understand?
15.In the last 12 months, how often did your healthcare provider listen carefully to you?
16.In the last 12 months, how often did your healthcare provider give you easy to understand information about these health questions or concerns?
17.In the last 12 months, how often did your healthcare provider seem to know the important information about your medical history?
18.In the last 12 months, how often did your healthcare provider show respect for what you had to say?
19.In the last 12 months, how often did your healthcare provider spend enough time with you?
20.In the last 12 months, did your healthcare provider order a blood test, x-ray, or other test for you?
21.In the last 12 months, when your healthcare provider 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?
22.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
.
23.In the last 12 months, how often were clerks and receptionists at your healthcare provider's office as helpful as you thought they should be?
24.In the last 12 months, how often did clerks and receptionists at your healthcare provider's office treat you with courtesy and respect?
25.In general, how would you rate your overall health?
26.In general, how would you rate your overall mental or emotional health?
27.What is your age?
28.What is your race? Mark one or more.