* 1. Please Select the location of your most recent visit:

* 2. When you made your most recent appointment with Horizon Family Medical Group, were we able to meet your date and time preference?

* 3. What is your Age? 

* 4. Were your expectations met during your last visit?

* 5. How satisfied were you with the courteousness/friendliness of our front desk during your visit?

* 6. How satisfied were you with the courteousness/friendliness of our nurses during your visit?

* 7. How satisfied were you with the time you waited before you were seen by your provider?

* 8. How satisfied were you with the courteousness/caring of your provider during your visit?

* 9. How well did your doctor listen to you during your visit?

* 10. How well did your doctor explain how to take your medicine(s)?

* 11. How satisifed were you with the self-care management tools given to you at your appointment?
(example: patient literature,referral information, classes)

* 12. How satisfied overall are you with the level of care you received during your last visit?

* 13. Did any Horizon staff member make your visit/interaction today extra special or meaningful? If so, please indicate the name of the person:

* 14. Do you ever recommend Horizon Family Medical Group to family and friends?

* 15. What, if anything, would you like to see done differently or what could be done to improve the service you received from Horizon Family Medical Group?

* 16. If you were referred to a specialist, did your primary care provider explain to you why you were being referred to a specialist?

* 17. If you were referred to a specialist, did the specialist have all your necessary health history information, such as lab or x-ray results and your medication list prior to your arrival?

* 18. If you were referred to a specialist, did they communicate their findings back to your primary care doctor? Basically did you get a sense that the two doctors were communicating with each other?

* 19. For patients who were hospitalized within the past 12 months: Did the Horizon care transition RN visit you and advocate for you during your hospital stay?

* 20. For patients who were hospitalized within the past 12 months: When you left the hospital, did you know how to reach the Horizon care transition RN with any questions or concerns?

* 21. For patients who were hospitalized within the past 12 months: Did you receive a call from your Horizon care transition RN to discuss your discharge instructions and medications?

* 22. For patients who were hospitalized within the past 12 months: Did you know that the Horizon care transition RN is available post hospital discharge for any questions or concerns?

* 23. For patients who were hospitalized within the past 12 months: Did the Horizon care transition RN schedule your follow up appointment post discharge?

* 24. Have you visited your (PCP) Primary Care Provider this year for your annual physical?

* 25. Have you and your provider discussed ways for you to maintain/improve your health, such as eating healthy, ways to stay active, or taking medications?

* 26. Did you (or will you) get a flu vaccination this season?

* 27. (age 65+) Have you ever had a pneumonia vaccination?

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