Recently, you or a family member received care from a Mobile Medical provider. Please take a few minutes to complete the following survey about this recent experience. Your response will remain confidential and use only to improve our Mobile Medical services for future patients and families.

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* 1. Date:

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* 2. How did you hear about Mobile Medical? (Please select only one)

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* 3. Location where you received care?

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* 4. Who provided your care?

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* 5. My provider took the time to listen to my needs and concerns:

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* 6. My provider helped me better understand my medical condition(s)

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* 7. My provider answered my questions related to my medical care

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* 8. My provider helped me with making difficult medical decisions

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* 9. My provider treated me and/or my family member with repsect

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* 10. My provider helped me effectively talk about my goals and preferences for future care

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* 11. What is your overall satisfaction with your provider

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* 12. Would you recommend Mobile Medical to a family or friend in need?

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* 13. How can we improve our Mobile Medical services?

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* 14. Who is responding to this survey?

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* 15. Patient gender?

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* 16. Patient age?

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* 17. Home zip code:

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