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* 1. Did the patient Decline to take the Survey?

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* 2. Date of appointment

Date

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* 3. Appointment Type

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* 6. Age of Patient

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* 7. Are you male or female? 

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* 8. Is your healthcare provider the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

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* 9.  In the last 12 months, when you phoned this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

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* 10. In the last 12 months, when you phoned your healthcare provider's office after regular office hours, how often did you get an answer to your medical question as soon as you needed?

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* 11. In the last 12 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?

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

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* 13. Wait time includes time spent in the waiting room and exam room. During your most recent visit, did you see this provider within 15 minutes of your appointment time?

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* 14. During your most recent visit, did your healthcare provider explain things in a way that was easy to understand?

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* 15. During your most recent visit, did your healthcare provider listen carefully to you?

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* 16. During your most recent visit, did your healthcare provider show respect for what you had to say?

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* 17. During your most recent visit, did your healthcare provider spend enough time with you?

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* 18. During your most recent visit, were clerks and receptionists at your healthcare provider's office as helpful as you though they should be?

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* 19. Using any number from 0-5, where 0 is the worst provider possible and 5 is the best provider possible, what number would you use to rate your healthcare provider?

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* 20. Would you recommend your healthcare provider's office to your family and friends?

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* 21. How convenient do you find our hours of operation?

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