Patient Experience Survey

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* 1. 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 Nurse Practitioner to when you actually saw them or someone else at the clinic?

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* 2. Did you get an appointment on the day you wanted or within an acceptable time?

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* 3. How many times in the last 12 months have you received care at a walk-in clinic or emergency room?

None

1-3

4-6

7-9

10+

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* 4. If you received care at a walk-in clinic or emergency room, what was the reason?

Other (please specify)

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* 5. Have you been admitted to hospital in the last 12 months?

Yes

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* 6. If yes, did you have follow up from the clinic about your admission to hospital?

Yes

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* 7. Do you take prescription medications on an ongoing basis?

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* 8. If yes, have you reviewed the mdications you take in the last 12 months with your NP or the Pharmacist?

Yes

Other/Don't know

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* 9. When you see your health care provider, how often do they or someone else at the clinic give you an opportunity to ask questions about your recommended treatment?

Always

Usually

Sometimes

Rarely

Never

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* 10. How often does your provider (this clinic) involve you in the decisions about your care/treatment?

Always

Usually

Sometimes

Rarely

Never

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* 11. Does your provider or the person you see at the clinic spend enough time with you during your appointments?

Always

Usually

Sometimes

Rarely

Never

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* 12. We are a team-based care model. Please tell us whom you saw in the past 12 months at our clinic. Please check all that apply.

Nurse Practitioner

Social Worker

Nurse

Respiratory Therapist

Pharmacist

Physician

Dietitian

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* 13. Do the staff make you feel welcomed here?

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* 14. How would you rate your overall experience with the clinic?

Excellent

Very Good

Good

Fair

Poor

Other (please specify)

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* 15. Would you recommend our services to friends or your family? Check one only

Definitely Yes

Probably Yes

Probably No

Definitely No

Patient Experience Survey

Question Title

* 1. 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 Nurse Practitioner to when you actually saw them or someone else at the clinic?

Question Title

* 2. Did you get an appointment on the day you wanted or within an acceptable time?

Question Title

* 3. How many times in the last 12 months have you received care at a walk-in clinic or emergency room?

Question Title

* 4. If you received care at a walk-in clinic or emergency room, what was the reason?

Question Title

* 5. Have you been admitted to hospital in the last 12 months?

Question Title

* 6. If yes, did you have follow up from the clinic about your admission to hospital?

Question Title

* 7. Do you take prescription medications on an ongoing basis?

Question Title

* 8. If yes, have you reviewed the mdications you take in the last 12 months with your NP or the Pharmacist?

Question Title

* 9. When you see your health care provider, how often do they or someone else at the clinic give you an opportunity to ask questions about your recommended treatment?

Question Title

* 10. How often does your provider (this clinic) involve you in the decisions about your care/treatment?

Question Title

* 11. Does your provider or the person you see at the clinic spend enough time with you during your appointments?

Question Title

* 12. We are a team-based care model. Please tell us whom you saw in the past 12 months at our clinic. Please check all that apply.

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* 13. Do the staff make you feel welcomed here?

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* 14. How would you rate your overall experience with the clinic?

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* 15. Would you recommend our services to friends or your family? Check one only

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* 16. Please list any areas you feel we could improve or offer any suggestions you may have.

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* 17. Can we share your comments on our website and social media?