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* 1. Appointment available within a reasonable time?

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* 2. Overall efficiency of check-in process?

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* 3. Wait time in the reception area?

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* 4. Wait time in the exam room?

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* 5. If appointment was delayed, how well did we do at keeping you informed of the delay?

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* 6. If a referral was required, how did we do at making the process easy for you?

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* 7. Courtesy of the person who checked you in?

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* 8. Caring / Concern of the NTHS staff?

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* 9. Professionalism of the NTHS staff?

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* 10. Helpfulness of the staff assisting you with a referral to an outside facility?

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* 11. Phone calls are returned promptly?

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* 12. Getting advice or help when needed during normal office hours?

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* 13. Explanation of your health concerns / questions?

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* 14. Test results available within a reasonable amount of time?

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* 15. Clarity and effectiveness of the health information material provided?

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* 16. Awareness of your medical home provider / team members?

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* 17. Willingness to listen to you carefully?

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* 18. Taking time to answer your questions?

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* 19. Amount of time spent with you?

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* 20. Explaining things in a way you can understand?

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* 21. Thoroughness of the examination?

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* 22. Instructions regarding medications and follow up care?

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* 23. Wait time for your in-clinic prescriptions to be filled?

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* 24. Wait time for mail order prescriptions to be filled?

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* 25. Interactions with the pharmacy staff?

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* 26. Overall satisfaction with the clinic?

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* 27. Overall comfort of the clinic?

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* 28. Cleanliness of the clinic?

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* 29. Ease of understanding signage and directions?

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* 30. Quality of your medical home care?

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* 31. Overall satisfaction of care from your medical home provider?

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* 32. How satisfied would you be if your patient records were available electronically?

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* 33. Suggestions for improvement:

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