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* 1. Date

Date / Time

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* 2. Gender

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* 3. Which race/ethnicity best describes you? (Please choose only one.)

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* 4. Age

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* 5. Which provider did you see at the Health Center?

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* 6. If you arrived for a scheduled appointment with your provider, how long did you have to wait (including the reception room and the exam room) to see her or him? (Select one)

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* 7. If you arrived for a walk-in visit with a provider, how long did you have to wait (including the reception room and the exam room) to see her or him? (Select one)

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* 8. How do you rate the items listed below? For each question, please
grade the care you receive from Very Poor (F) to The Best (A+) by Selecting one number on each line. If something does not apply to you, circle “Does Not Apply To Me.”

  Poor (F) Fair (C) Good (B) Excellent (A) Does Not Apply To Me
a. Convenience of getting to the clinic...
b. Quality of treatment you receive...
c. Staff listening to what you say…
d. Answers to your questions…
e. Hours that the clinic is open…
f. Ease of contacting us after hours...
g. Ease of reaching the staff by phone when you have a problem…
h. Friendliness and courtesy shown to you by the receptionist and other front desk staff…
i. Explanation about prescribed medicines…
j. Explanation of procedures and test results…
k. How long you wait in the reception area…
l. Amount of time spent waiting in the exam room before seeing the provider…
m. Support you may have received regarding healthy habit changes…
n. Friendliness and courtesy shown to you by medical and/or dental assistants...
o. Availability of health education, materials or programs to enhance your health …
p. Overall quality of care & services provided by the clinic...

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* 9. How likely are you to recommend Aria Community Health Center to a family member or friend?

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* 10. What changes could we make to become a better place to get Health Care?

Please feel free to make any other comments about the services you receive below:

0 of 10 answered
 

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