Please answer all questions as they relate to visits and communications with this office in the last 12 months.

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* 1. How long have you or your child (children) been coming to this office?

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* 2. Which provider do you or your child see the most?

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* 3. How many days do you usually have to wait for an appointment when you or your child needs care right away (for illness or accident)?

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* 4. Did this office give you information about what to do if you or your child needs care during evenings, weekends, or holidays?

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* 5. How often were you able to get the care/advice you or your child needed from this office during evenings, weekends, or holidays?

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* 6. When you phoned this office during regular office hours, how often did you get an answer to your medical question that day?

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* 7. When you phoned this office AFTER regular office hours, how often did you get an answer to your medical question within 1 hour?

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* 8. Wait time includes time spent in the waiting room and the exam room. How often did you or your child see the doctor within 15 minutes of his/her appointment time?

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* 9. Some offices remind patients between visits about tests, treatment or appointments. Did you receive any reminders about you or your child's care from this office in between visits?

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* 10. Is the staff courteous and responsive to your needs?

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* 11. How often did this provider show interest in your questions and concerns?

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* 12. How often did this provider answer all of your questions to your satisfaction?

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* 13. Did the provider talk with you about specific goals for you or your child's health?

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* 14. Does this provider give easy to understand information regarding you or your child's health?

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* 15. Has the provider asked you if there are things that make it hard for you to take care of you or your child's health?

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* 16. Does the provider seem to know the important information about you or your child's medical history?

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* 17. Did the provider discuss healthy eating habits and the importance of physical activity?

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* 18. Were lab tests and other test results presented in a way that was easy to understand?

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* 19. Did the provider give you instructions about what to do to take care of you or your child's illness or health condition?

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* 20. In the last 12 months, did you/your child take any prescription medication?

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* 21. Did you and the provider discuss at each visit all prescription medications you or your child were taking?

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* 22. Has the provider spoken to you about you or your child's learning ability and the kinds of behaviors that are normal for your or the child's age?

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* 23. Has the provider spoken to you about you or your child's moods and emotions?

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* 24. Specialists are doctors such as surgeons, heart doctors, skin doctors and other doctors who specialize in one area of health care. In the last 12 months, did you or your child see a specialist for a particular health problem?

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* 25. If yes, how often did your primary provider seem informed and up-to-date about the care you or your child received from the specialist?

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* 26. How often do you feel the provider spent enough time with you or your child?

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* 27. Do you feel you can trust this provider with you or your child's medical care?

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* 28. Would you recommend this provider to your family and friends?

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* 29. Please tell us how we can improve the care and services you received in the last 12 months.

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* 30. Patient Name (optional)

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