* 1. Our records show that you received care from a Goshen Medical Center provider. Is that correct?

* 2. What site did you visit to receive care from the Goshen Medical Center provider?

* 3. Is your Goshen Medical Center 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 Goshen Medical Center provider?

* 5. In the last 12 months, how many times did you visit your Goshen Medical Center provider?

* 6. In the last 12 months, did you phone your Goshen Medical Center provider’s site to get an appointment for an illness, injury, or condition that needed care right away?

* 7. In the last 12 months, when you phoned your Goshen Medical Center 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 12 months, did you make any appointments for a check-up or routine care with your Goshen Medical Center provider?

* 9. In the last 12 months, when you made an appointment for a check-up or routine care with your Goshen Medical Center provider, how often did you get an appointment as soon as you needed?

* 10. In the last 12 months, did you phone your Goshen Medical Center provider’s office with a medical question during regular office hours?

* 11. In the last 12 months, when you phoned your Goshen Medical Center 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 12 months, did you phone your Goshen Medical Center provider’s office with a medical question after regular office hours?

* 13. In the last 12 months, when you phoned your Goshen Medical Center provider’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?

* 14. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see your Goshen Medical Center provider within 15 minutes of your appointment time?

* 15. How long has it been since your most recent visit with your Goshen Medical Center provider?

* 16. Wait time includes time spent in the waiting room and exam room. During your most recent visit, did you see your Goshen Medical Center provider within 15 minutes of your appointment time?

* 17. During your most recent visit, did your Goshen Medical Center provider explain things in a way that was easy to understand?

* 18. During your most recent visit, did your Goshen Medical Center provider listen carefully to you?

* 19. During your most recent visit, did you talk with your Goshen Medical Center provider about any health questions or concerns?

* 20. During your most recent visit, did your Goshen Medical Center provider give you easy to understand information about these health questions or concerns?

* 21. During your most recent visit, did your Goshen Medical Center provider seem to know the important information about your medical history?

* 22. During your most recent visit, did your Goshen Medical Center provider show respect for what you had to say?

* 23. During your most recent visit, did your Goshen Medical Center provider spend enough time with you?

* 24. During your most recent visit, did your Goshen Medical Center provider order a blood test, x-ray, or other test for you?

* 25. Did someone from your Goshen Medical Center provider’s site follow up to give you those results?

* 26. 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 Goshen Medical Center provider?

  10 Best provider possible 9 8 7 6 5 4 3 2 1 0 Worst provider possible
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* 27. Would you recommend your Goshen Medical Center provider’s office to your family and friends?

* 28. During your most recent visit, were clerks and receptionists at your Goshen Medical Center provider’s office as helpful as you thought they should be?

* 29. During your most recent visit, did clerks and receptionists at your Goshen Medical Center provider’s office treat you with courtesy and respect?

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

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

* 32. What is your age?

* 33. Are you male or female?

* 34. What is the highest grade or level of school that you have completed?

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

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

* 37. Are you a member of one or more of the following population groups?

* 38. Did someone help you complete this survey?

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

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