* In the last 12 months, how often did the clerks and receptionists at this office treat you with courtesy and respect?

* In the last 12 months, how many days did you usually have to wait for an appointment when your child needed care right away?

* In the last 12 months, how often were you able to get the care your child needed from our office during evenings, weekends, or holidays?

* Please identify the physician who you consider your primary doctor or the physician who your child has seen or spoken to most often over the past 12 months and answer the following questions about that doctor.

* In the last 12 months, how often did your child see this provider within 15 minutes of his or her appointment time?

* In the last 12 months, how often did this provider seem to know the important information about your child's medical history and seem informed and up to date about the care your child received from any specialists?

* In the last 12 months, did this provider talk about the following topics?

  Yes No N/A
Your child's learning ability?
Behaviors that are normal for your child at this age?
How's your child's body growing?
Your child's moods and emotions?
How to keep your child from getting injured?
How much time your child spends on a computer and in front of a TV?
How much or what kind of food your child eats?
How much or what kind of exercise your child gets?

* In the last 12 months, when a blood test, x-ray, or other test was ordered for your child, how often did someone from this provider’s office follow up to give you those results?

* In the last 12 months, how often did this provider give you easy to understand information about health questions or concerns you had?

* In the last 12 months, how often did this provider show respect for what you had to say?

* In the last 12 months, how often did this healthcare provider listen carefully to you?

* In the last 12 months, how often did this provider explain things in a way that was easy for your child to understand?

* In the last 12 months, how often did this provider spend enough time with you and your child?

* Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

  Worst provider possible Best provider possible
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* What is your child's age?

* Is your child male or female?

* What is your race? Please choose one or more.

* What is your age?

* What is the highest grade or level of school that you have completed?

* How are you related to the child?

* Thank you for taking the time to complete this survey. We need your feedback to determine the best ways to improve the care of the children, adolescents and parents in our practice. Please add any comments or suggestions in the space below.

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