Patient Satisfaction Survey - Medical Services

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* 1. Today's Date:

Date / Time

Date

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* 2. Gender

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* 3. Race/Ethnicity:

Native American

Hispanic

Black/African American

White

Other (please specify)

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* 4. The provider I usually see is:

Dr. Catherine Taylor

Dr. Michael Emery

Dr. Michael Hennelly

Pamela Logan, NP

Dawn Dozhier, PA

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* 5. Please respond to the following questions based on your experience at this clinic over the past 12 months.

	Always	Usually	Sometimes	Never
When you phoned this clinic to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?	When you phoned this clinic to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed? Always	When you phoned this clinic to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed? Usually	When you phoned this clinic to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed? Sometimes	When you phoned this clinic to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed? Never
Wait time includes time spent in the waiting room and exam room. How often did you see this provider within 15 minutes of your appointment?	Wait time includes time spent in the waiting room and exam room. How often did you see this provider within 15 minutes of your appointment? Always	Wait time includes time spent in the waiting room and exam room. How often did you see this provider within 15 minutes of your appointment? Usually	Wait time includes time spent in the waiting room and exam room. How often did you see this provider within 15 minutes of your appointment? Sometimes	Wait time includes time spent in the waiting room and exam room. How often did you see this provider within 15 minutes of your appointment? Never
How often did this provider explain things in a way that was easy to understand?	How often did this provider explain things in a way that was easy to understand? Always	How often did this provider explain things in a way that was easy to understand? Usually	How often did this provider explain things in a way that was easy to understand? Sometimes	How often did this provider explain things in a way that was easy to understand? Never
How often did this provider listen carefully to you?	How often did this provider listen carefully to you? Always	How often did this provider listen carefully to you? Usually	How often did this provider listen carefully to you? Sometimes	How often did this provider listen carefully to you? Never
When this provider ordered a blood test, x-ray, or other tests for you, how often did someone from the clinic follow up to give you the results?	When this provider ordered a blood test, x-ray, or other tests for you, how often did someone from the clinic follow up to give you the results? Always	When this provider ordered a blood test, x-ray, or other tests for you, how often did someone from the clinic follow up to give you the results? Usually	When this provider ordered a blood test, x-ray, or other tests for you, how often did someone from the clinic follow up to give you the results? Sometimes	When this provider ordered a blood test, x-ray, or other tests for you, how often did someone from the clinic follow up to give you the results? Never
How often were clerks and receptionists at this clinic as helpful as you thought they should be?	How often were clerks and receptionists at this clinic as helpful as you thought they should be? Always	How often were clerks and receptionists at this clinic as helpful as you thought they should be? Usually	How often were clerks and receptionists at this clinic as helpful as you thought they should be? Sometimes	How often were clerks and receptionists at this clinic as helpful as you thought they should be? Never

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* 6. Please respond to the following questions based on your experience at this clinic over the past 12 months.

	Yes	No
Did you and anyone from this clinic talk at each visit about all the prescription medicines you were taking?	Did you and anyone from this clinic talk at each visit about all the prescription medicines you were taking? Yes	Did you and anyone from this clinic talk at each visit about all the prescription medicines you were taking? No
When you talk about starting or stopping a prescription medication, did this provider ask you what you thought was best for you?	When you talk about starting or stopping a prescription medication, did this provider ask you what you thought was best for you? Yes	When you talk about starting or stopping a prescription medication, did this provider ask you what you thought was best for you? No
Did anyone in this clinic talk with you about specific goals for your health?	Did anyone in this clinic talk with you about specific goals for your health? Yes	Did anyone in this clinic talk with you about specific goals for your health? No
Did you and anyone in this clinic talk about a personal problem, family problem, alcohol use, drug use, or a mental or emotional issue?	Did you and anyone in this clinic talk about a personal problem, family problem, alcohol use, drug use, or a mental or emotional issue? Yes	Did you and anyone in this clinic talk about a personal problem, family problem, alcohol use, drug use, or a mental or emotional issue? No
Some offices remind patients between visits about tests or appointments. Did you get any reminders from this clinic between visits?	Some offices remind patients between visits about tests or appointments. Did you get any reminders from this clinic between visits? Yes	Some offices remind patients between visits about tests or appointments. Did you get any reminders from this clinic between visits? No
Did this clinic give you information about what to do if you needed care during evenings, weekends, or holidays?	Did this clinic give you information about what to do if you needed care during evenings, weekends, or holidays? Yes	Did this clinic give you information about what to do if you needed care during evenings, weekends, or holidays? No

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* 7. How many days did you usually have to wait for an appointment when you needed care right away?

Same day

1 day

2 to 3 days

4 to 7 days

More than 7 days

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* 8. 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 this provider?

0 worst

1

2

3

4

5

6

7

8

9

10 best

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* 9. Comments: