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GAP Patient Survey
1.
How long have you been a patient of any GAP location?
I am a new patient (this was my first visit)
Less than 1 year
1-5 years
6-10 years
More than 10 years
2.
In the last 12 months, how many times did you visit one of our facilities?
(Includes Piedmont, Salem, Clemmons, and both endoscopy centers.)
1 time
2-3 times
4-5 times
6-9 times
10 or more times
3.
Which location do you typically visit?
Winston-Salem
Kernersville
Clemmons
4.
Which provider(s) do you normally see?
Dr. Austin
Dr. Barry
Dr. Cengia
Dr. Connolley
Dr. Cornella
Dr. Holmes
Dr. Jones
Dr. McKimmie
Dr. Mixon
Dr. Murphy
Dr. Patwa
Dr. Peters
Dr. Scott
Dr. Smith
Dr. Sweeney
Ayako Allen, NP-C
Paul Gregory, NP-C
Christa Hubert, PA-C
Kari McChesney, NP-C
Kim Ray, PA-C
Ashley Schmidt, NP-C
Chi Shatalov, PA-C
5.
What is your age?
16-25
26-35
36-49
50-64
65 or older
6.
Do you use MyChart to communicate with our staff?
Yes
No
I don't know what MyChart is
7.
How did you hear about us?
Friend, family member, or colleague
Referred by a physician
Community event
Advertisement
Phonebook
Internet
Other (please specify)
8.
Would you recommend GAP to a friend, family member, or colleague?
Yes
No
9.
What obstacles might keep you from receiving proper care with us?
Access to transportation
Distance from home
Financial/Insurance
Language barrier
Health status due to age
Health status due to mental/physical disability
Chronic illness
Not applicable to me
Other (please specify)
10.
In the last 12 months, how often have you been able to receive routine, urgent and after-hours care from us when you needed it?
Never
Sometimes
Usually
Always
11.
In the last 12 months when you called with a question, how often did you get an answer that same day?
Never
Sometimes
Usually
Always
I haven't called with a question
12.
In the last 12 months when blood work, procedures or other tests were ordered for you, how often did someone from GAP follow-up within 10 business days to give you those results?
Never
Sometimes
Usually
I haven't had any testing done
13.
In the last 12 months, how often do you feel that you were given enough information about managing your health?
Never
Sometimes
Usually
Always
I haven't had any health conditions that need managing
14.
In the last 12 months, how often did you feel that the providers and staff listened to, respected, and took the necessary time to answer your questions?
Never
Sometimes
Usually
Always
15.
In the last 12 months, how often did you feel that GAP providers have sufficiently communicated your care with your primary care physician?
Never
Sometimes
Usually
Always
16.
Please enter any comments or suggestions here.