* 1. Were your phone calls were returned in a timely manner?

* 2. How would you rate the length of time in the waiting room at HCI before your appointment?

* 3. How was the waiting time in the reception?

* 4. Waiting time in the exam room?

* 5. How was the personal manner, courtesy, respect, sensitivity and friendliness of our providers?

* 6. How was the personal manner, courtesy, respect, sensitivity and friendliness of our reception staff? 

* 7. How was the personal manner, courtesy, respect, sensitivity and friendliness of our nurses, medical or dental assistants?

* 8. How were the skills and abilities of your provider?

* 9. How was the amount of time your provider spent with you during your visit? 

* 10. Was your provider willing to listen carefully to your comments?

* 11. Did your provider explain things in a way you could understand?

* 12. How were the skills and abilities of your nurses, medical or dental assistants?

* 13. How were the instructions in regards to your diagnosis/follow-up care/future appointments?

* 14. If medications, labs or referrals were needed, were the instructions clear? 

* 15. How were the health education and self management handouts?

* 16. How was your overall satisfaction of our clinic?

* 17. What was your overall satisfaction in regards to the care you received from our staff?

* 18. Who is your provider and/or nurse?

* 19. The following questions are OPTIONAL

* 20. What is your age?

* 21. What is your ethnicity?

* 22. Do you have health insurance?

* 23. How many times have you been to Healthy Connections in the past year?

* 24. If this is your first visit, how did you hear about Healthy Connections?

* 25. Where would you go for medical care if you had not found Healthy Connections?

* 26. Have you ever put off  health care because of the cost?

* 27. Have you ever put off your child's health care because of cost?

* 28. Where have you received medical care in the past 3 years?

* 29. If someone in your home uses internet, how is it accessed?

* 30. Do you use text messaging by phone? 

* 31. Is there anything that could have made your visit better? (Suggestions/Comments/Kudos)

* 32. Is there a special staff member you would like to recognize?

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