* 1. Are you a current client of Country Roads?

* 2. Are you a client who has recently been transferred to us from another doctor or a family health team?

* 3. Which office locations have you visited ( check all that apply)

* 4. Overall, how would you rate your experience with Country Roads so far?

* 5. To what degree would you say that you feel comfortable and welcome at Country Roads CHC?

* 6. Thinking about visits you have had at Country Roads, how would you rate the following?

  Excellent Very Good Good Fair Poor
Your confidence in the Doctor/Nurse Practitioner or other health care provider(s) you saw during the visit
Your confidence that your health information was treated with the level of privacy/confidentiality you expect
The usefulness of the information you recieved for managing your care and treatment
Your overall experience with the visit you just had with us 

* 7. As a patient of ours, which County Roads Services have you used?

* 8. If you indicated that you have seen more then one health care provider during your visits with us over the last year or so, thinking of these people as a group, how often ...

  Excellent  Very good  Good  Fair  Poor 
Do they seem to know about your medical history?
Were they consistent in telling you about your care and treatment?
Did they seem to work well together in caring for you?

* 9. The last time you were sick or were concerned you had a health problem, did you get an appointment when you wanted it?

* 10. The last time you were sick or were concerned you had a health problem, how many days did it take from when you first tried to see your doctor or nurse practitioner to when you actually saw him/her or someone else in their office?

* 11. When you see your Doctor or Nurse Practitioner, how often do they or someone else in the office .....

  Always  Often  Sometimes Rarely  Never 
Give you and opportunity to ask questions about recommended treatment 
Involve you as much as you want to be in decisions about your care and treatment 
Spend enough time with you

* 12. Thinking about the MAIN health care provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on the following ....?

  Excellent  Very Good Good Fair Poor
Listened to your concerns
Explained things in a way that was easy to understand 
Encouraged you to ask questions 
Spent enough time with you 

* 13. Do you have any of the following? Check all that apply.

* 14. In general, how would you describe your health?

* 15. Would you recommend us to your friends or to your family?

* 16. Please Share with us the things that you feel we do particularly well.

* 17. Please share with us the things that you believe we could improve upon.

* 18. If you would like to discuss anything directly with a member of our management team, please include your name and contact number. We are always looking for ways to improve and we are happy to hear form you!

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