* 1. Please select Insurance

* 2. Select type of Appointment

* 3. Do you feel you can be honest with your physician about your life style choices?

* 4. How much does your physician know about your life style choices (good or bad)?

* 5. If you have visited the Emergency Room in the past, what was your main motivation to go there versus seeing your provider?  

* 6. If you are taking certain medications on a regular basis, has your physician or insurance talked to you about mail-order options?

* 7. If you have NOT seen the physician for a physical/well exam, what is your biggest obstacle for not making an appointment?

* 8. If your physician's office offered after- hours Virtual (Camera/Webcam) Appointments, would you see that as a benefit?

* 9. Have you filled out a form (e.g. HIPAA, Consent to Disclose Health Information) that asked who your provider can share medical information with?

* 10. Did you know your physician's office can be reached 24/7?

* 11. In the past 6 months did anyone on your Healthcare team ask if you felt down, depressed or hopeless?

* 12. How do your prefer to schedule your Doctor visits?

* 13. How likely is it that you would recommend your provider to a friend or colleague?

Not at all likely
Extremely likely
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