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* 2. If you are completing this survey for someone else, who are you completing it for?

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* 3. If you have visited the clinic in the last 12 months, were there times when you: (check all that apply)

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* 4. How did you book your last appointment?

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* 5. Thinking of the last time you were sick or concerned about a health issue, did you get an appointment as soon as you wanted?

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* 6. Thinking of the last time you were sick or concerned about a health issue, was your appointment for:

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* 7. Thinking of the the last time you were sick or concerned about a health issue, how many days did you wait for your appointment?

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* 8. Thinking about the MAIN healthcare provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on how well they knew your medical history?

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* 9. Thinking about the MAIN healthcare provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on how well they listened to your concerns?

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* 10. Thinking about the MAIN healthcare provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on using language that you could understand?

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* 11. Thinking about the MAIN healthcare provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on how well they explained things in a way that was easy to understand?

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* 12. Thinking about the MAIN healthcare provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on how sensitive they were to your needs and preferences?

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* 13. Thinking about the MAIN healthcare provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on how they treated you with dignity and respect?

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* 14. Thinking about the MAIN healthcare provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on whether or not they gave you clear instructions about what to do after your visit?

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* 15. Thinking about the MAIN healthcare provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on your overall experience with them?

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* 16. When you visited the clinic, were you included in the decisions about your care?

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* 17. Thinking about your most recent visit, on a scale of poor to excellent, how would you rate the cleanliness of the clinic.

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* 18. Thinking about your most recent visit, on a scale of poor to excellent, how would you rate the physical comfort of the clinic.

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* 19. Thinking about your most recent visit, on a scale of poor to excellent, how would you rate your confidence in the healthcare providers.

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* 20. Thinking about your most recent visit, on a scale of poor to excellent, how would you rate your confidence that your health information was treated confidentially.

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* 21. Thinking about your most recent visit, on a scale of poor to excellent, how would you rate your overall experience with the visit you had with us.

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* 22. How satisfied are you with the service by the receptionists and staff at the clinic?

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* 23. Are you aware of the additional programs and services at our clinic? (ie. Footcare, Diabetes education and support programs, health eating counselling, mental health counselling, insomnia program, smoking cessation program, anxiety and depression group, cardio-pulmonary rehab program)

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* 24. How satisfied are you with the programs and services offered at the clinic?

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* 25. Are there other services or programs you would like to see?

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* 26. In the past 12 months, have you taken one or more prescription medications on a regular basis?

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* 27. If yes to Question 26, did someone review the prescription medications with you?

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* 28. If yes to Question 27, please indicate whom it was with:

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* 29. Optional Feedback: If you would like to provide additional feedback, please use the space below.  Also keeping in mind that the survey is completely anonymous, and you are comfortable letting us know who your healthcare provider is, please indicate below.

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* 30. Thinking of your overall experience with your clinic, what are two (2) things we do well?

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* 31. Thinking of your overall experience with your clinic, what are two (2) things we could improve upon?

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* 32. My healthcare provider is:

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