* 1. What is your postal code?

* 2. Are you:

* 3. What is your age?

* 4. Thinking back to within the past year or the last time you were sick or concerned you had a health problem, how many days did it take from when you first tried to see a medical practitioner to when you actually saw him/her in their office?

* 5. When you are greeted at reception or spoken to on the phone is the staff sensitive to your needs and are you treated with dignity and respect?

* 6. When you see your Dr. or Nurse practitioner, how often do they or someone else in the office involve you as much as you want to be in decisions about your care and treatment?

* 7. If you are a client aged 50- 74 years of age. Have you had a fecal occult blood test for bowel cancer screening within past two years, or sigmoidoscopy or barium enema within five years, or a colonoscopy within the past 10 years

* 8. If you are woman aged 21-69 years of age have you had a Pap test within the past 3 years as part of Cancer prevention screening?

* 9. If you have diabetes and are aged 40 or older have you had two or more glycated hemoglobin (HbA1C) tests within the past 12 months?

* 10. If you have been admitted to hospital in the past year did you make an appointment with your family Dr. within seven days after release if you were hospitalized for certain conditions such as: COPD (Chronic Obstructive Pulmonary Disease-Breathing Problems) CHF (Congestive Heart Failure) Pneumonia, Renal Failure (Kidney Disease), started on an Anti-Coagulation (Blood Thinners) Abnormal Insulin levels, Cardiac (heart attack), Stroke, Falls or a Mental Illness or Addiction

* 11. If you need care after hours in this area where do you go?

* 12. Overall how would you rate the care you received at the Grand Bend Area CHC?

* 13. I always feel comfortable and welcomed at the Grand Bend Area CHC

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