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* 1. Do you currently have a family doctor?

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* 2. If Yes, which clinic do you visit your family doctor at?

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* 3. If No, please state reason why you do not have a family doctor?

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* 4. When was the last time you visited your family doctor?

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* 5. How many days do you usually have to wait until you can get an appointment with your family doctor?

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* 6. When you arrived for your last appointment at your family doctor's office, how long did you have to wait to see your doctor?

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* 7. On that occasion, about how much time did you spend with your family doctor?

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* 8. On that occasion, please check off all that apply to your experience with your family doctor:

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* 9. During this experience, did your family doctor treat you with courtesy and respect?

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* 10. In the last 12 months, was there a time when you wanted to see your family doctor for something urgent, but couldn't due to any of the following reasons?

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* 11. On that occasion this happened, what did you do?

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* 12. Did you know there is a Primary Care Network (PCN) in your community?

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* 13. Has your family doctor made you aware if they are part of the Camrose PCN and what programs/services you have access to?

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* 14. In the last 12 months, have you been referred to or been seen by a healthcare provider at the PCN (nurse, dietitian, pharmacist, exercise specialist, behavioural health consultant)?

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* 15. If yes, please check all that apply:

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* 16. During this experience, did the PCN healthcare provider treat you with courtesy and respect?

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* 17. How many times a year have you had to use the hospital emergency department and/or walk-in clinic because access to after hours care was limited or unavailable?

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* 18. Are you satisfied with the options in your community for after hours health care access? (ie: walk-in clinic, emergency department)

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* 19. How do you usually get general health information or advice? Please check all that apply.

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* 20. Have you visited the Camrose PCN website at www.camrosepcn.com? 

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* 21. How often do you use social media to access information about your community?

  Several times per day Once per day Weekly Monthly Less than yearly Never
Facebook
Twitter
Instagram

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* 22. Which local media do you access for information about your community? How often?

  Regular Reader/Listener Occasionally (A couple times a month)  Never
Camrose Canadian
Camrose Booster
Camrose Morning News
Community Press
Tofield Mercury
Bashaw Star
Cam FM
840 CFCW
Channel 10 - Cable TV of Camrose

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* 23. In your opinion, what is the best way for community members to be involved in the planning of primary health care services?

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* 24. Do you feel you have enough input into discussions about the primary health care services offered in your community?

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* 25. Would you be interested in receiving an on-line Camrose PCN newsletter informing you of programs, services and upcoming events?

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* 26. Gender

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* 27. What is your age group?

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* 28. What is the first three characters of your postal code?

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* 29. Any additional comments you would like to add:

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* 30. If you would like to enter the draw for the iPad mini, please enter your contact information below.  Your information will only be used for the prize draw, and then discarded.  We will only send you information if you put your email earlier in the survey (question #28).

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