YOUR PROVIDER

* 1. Our records show that you received care from your heathcare provider. Please choose the provider that you received care from.

* 2. Which location was your appointment?

* 3. 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?

* 4. How long have you been going to your healthcare provider?

YOUR CARE FROM THIS PROVIDER IN THE LAST 6 MONTHS
These questions ask about your own health care.  Do NOT include care you received when you stayed overnight in a hospital.  Do NOT include the times you went for dental care visits.

* 5. In the last 6 months, how many times did you visit your heathcare provider?

* 6. In the last 6 months, did you phone your healthcare provider’s office to get an appointment for an illness, injury, or condition that needed care right away?

* 7. In the last 6 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?

* 8. In the last 6 months, did you make any appointments for a check-up or routine care with your healthcare provider?

* 9. In the last 6 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?

* 10. In the last 6 months, did you phone your healthcare provider’s office with a medical question during regular office hours?

* 11. In the last 6 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?

* 12. In the last 6 months, how often did your healthcare provider explain things in a way that was easy to understand?

* 13. In the last 6 months, how often did your healthcare provider listen carefully to you?

* 14. In the last 6 months, how often did your healthcare provider seem to know the important information about your medical history?

* 15. In the last 6 months, how often did your healthcare provider show respect for what you had to say?

* 16. In the last 6 months, how often did your healthcare provider spend enough time with you?

* 17. In the last 6 months, did your healthcare provider order a blood test, x-ray, or other test for you?

* 18. In the last 6 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?

* 19. 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
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Please answer these questions about the provider named in Question1of this survey.

* 20. In the last 6 months, did you take any prescription medicine?

* 21. In the last 6 months, how often did you and someone in your provider's office talk at each visit about all the prescription medicines you were taking?

CLERKS AND RECEPTIONISTS AT THIS PROVIDER'S OFFICE

* 22. In the last 6 months, how often were clerks and receptionists at your healthcare provider's office as helpful as you thought they should be?

* 23. In the last 6 months, how often did clerks and receptionists at your healthcare provider's office treat you with courtesy and respect?

ABOUT YOU

* 24. In general, how would you rate your overall health?

* 25. In general, how would you rate your overall mental or emotional health?

* 26. What is your age?

* 27. Are you male or female?

* 28. What is the highest level of school that you have completed?

* 29. Are you of Hispanic or Latino origin or descent?

* 30. What is your race? Mark one or more.

* 31. Did someone help you complete this survey?

* 32. How did that person help you? Mark one or more.

* 33. Comments (If you need someone to contact you regarding your comment, please leave your name and phone number at the end of your comments.)

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