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

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

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

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* 4. Waiting time in the exam room?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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* 19. The following questions are OPTIONAL

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* 20. What is your age?

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* 21. What is your ethnicity?

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* 22. Do you have health insurance?

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

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

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

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

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

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

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

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* 30. Do you use text messaging by phone? 

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

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

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