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* 1. Our records show that you received care from your heathcare provider. Please choose the provider that you received care from.

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* 2. Which location was your appointment?

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* 3. How long have you been going to your healthcare provider?

These questions ask about your own health care.  Please answer questions according to your most recent office visit.  Do NOT include care you received when you stayed overnight in a hospital.  Do NOT include the times you went for dental care visits.

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* 4. When scheduling your most recent appointment, was your appointment scheduled within a reasonable time frame?

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* 5. Was your most recent appointment for a check-up or routine care with your healthcare provider or for an illness, injury, or condition other than routine care?

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* 6. Did you get a reminder from your provider's office for your most recent appointment?

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* 7. Wait time includes time spent in the waiting room and exam room. How long was your wait for your most recent appointment?

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* 8. At your most recent appointment, did anyone in your provider's office verify all the prescription and over-the-counter medicines you are taking?

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* 9. Did your healthcare provider give you easy to understand information about your health questions or concerns during your most recent appointment?

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* 10. In the last 6 months, how often did your healthcare provider spend enough time with you?

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* 11. In the last 6 months, when your healthcare provider ordered a blood test, x-ray, or other test for you, how often did you receive results within 1 -2 weeks?

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* 12. When you talked about starting or stopping a prescription medicine, how much did your provider talk about the reasons you might want or not want to take a medicine?

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* 13. When you phoned your healthcare 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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* 14. In the last 6 months, if you were seen by a specialist, was the provider named in Question 1 informed and up-to-date about the care you received from the specialist?

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* 15. In the last 6 months, how often were you able to get the care you needed from this provider's office during evenings, weekends, or holidays?

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* 16. In the last 6 months, did anyone in your provider's office talk with you about specific goals for your health?

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* 17. In the last 6 months, did anyone in this provider's office ask you if there are things that make it hard for you to take care of your health?

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* 18. 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 your healthcare provider?

  10 Best provider possible 9 8 7 6 5 4 3 2 1 0 Worst provider possible
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* 19. What is your age?

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* 20. What is the highest level of school that you have completed?

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* 21. What is your race? Mark one or more.

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* 22. Comments.
This survey is anonymous.  If you would like a return call concerning your appointment, please enter your name and contact information and someone will contact you.

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* 23. How did hear about our office?

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