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* 1. Which office locations have you visited?

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* 2. How long have you been a client of Country Roads Community Health Centre?

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* 3. Please share with us your age range

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* 4. Which staff member did you see during your most recent visit to Country Roads?

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* 5. Overall, how would you rate the care and services you received at CRCHC?

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* 6. When you see your health care provider, how often do they or someone else in the office .....

  Always Often Sometimes Rarely  Never
Give you an 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?
Listen to your concerns?
Explain things in a way that is easy to understand?

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

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* 8. How many days did it take from when you first tried to see your health care provider to when you actually SAW him/her or someone else in their office?

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* 9. Do you always feel comfortable and welcome at CRCHC?

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* 10. If no, please tell us the reason(s) (you may select more than one box)

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

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* 12. How would you rate the following?

  Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree
You know how to make a suggestion or complaint
The buildings are accessible to people with disabilities 
You would refer a family or friend to CRCHC
Staff are sensitive to your needs and preferences
Staff treat you with dignity and respect 
My privacy is respected

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

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* 14. 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 from you!

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