* 1. In this practice, when I call to get an appointment, I am able to get an appointment as soon as I feel I need one.

* 2. When I call the office during office hours, I get an answer to my medical question that same day.

* 3. When I call the office after office hours, I get an answer to my medical question as soon as I need it.

* 4. My provider listens to my concerns and questions.

* 5. My provider gives me easy to understand instructions about how to take care of my health problems or concerns.

* 6. When my provider orders blood tests, x-rays, other tests, someone from the office follows up to give me the results.

* 7. My provider communicates with other health professionals about my care (such as specialists, therapists).

* 8. In the last 12 months, how often did someone in the practice talk with you about specific goals for your health?

* 9. During your visit today, how acceptable was the time the provider spent with you?

* 10. Please specify the patient’s ethnicity.

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