Client Experience Questionnaire

Tell us about your experience!  Your feedback helps us to improve the way we provide care.  This questionnaire was built upon our Patient Values (Dignity, Respect and Trust, Information Sharing, Participation, Accessibility and Responsiveness, and Quality).

We do not collect personal information unless you request a follow-up.

If the question does not apply, please leave blank

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* Did you attend your appointment virtual or in person?

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* If virtual did you attend via telephone or video conference?

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* Which location did you visit the Mobile Clinic:

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* Dignity, Respect and Trust:
(If the question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a.  I was treated with respect.
b.  My privacy was respected as best it could be.

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* Dignity, Respect and Trust:
(If the question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
c. My cultural needs were considered. (e.g. individuals’ own beliefs, customs, social standards, traditions or religious beliefs)

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* Dignity, Respect and Trust:
(If the question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
d.  Before providing care, staff members introduced themselves to me, where appropriate.
e.  In general, staff were compassionate.

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* Information Sharing
(If the question does not apply, leave blank)

  Always Usually Sometimes Never
a. Staff talked to me about what medications I am taking at home. (e.g. prescription, supplements, herbal, etc.)
b. Staff talked to me about my health care options.  (e.g. procedures/tests/treatments)
c.  My health care provider used words I could understand.
d.  I had the necessary information needed to make good decisions about my health.
e.  The staff kept my information confidential and secure.

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* Participation:
(If the question does not apply, leave blank)

  Always Usually Sometimes Never
a.  Staff involved me or my family/support system in making decisions about my care.
b.  I was encouraged to take part in my care as much as I was able.
c.  My choices were respected.
d.  I was comfortable expressing concerns about my care.

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* Accessibility and Responsiveness:
(If the question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a.  My care was well coordinated.
b.  I was cared for in a timely manner.
c.  I had access to the care I needed.
d.  My concerns were taken seriously.

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* Quality:
(If the question does not apply, leave blank)

  Always Usually Sometimes Never
a.  I saw the health care provider(s) clean their hands before providing my care.
b.My identity was confirmed before receiving care. (e.g. asked my name, asked my date of birth)

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* Quality:
(If the question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
c.  Staff discussed with me how to prevent falls.
d.  I felt staff were up to date on the skills needed to provide my care.
e.  Overall, I was satisfied with the quality of care I received.

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* Mobile Clinic Program Related Questions:
(If the question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a. The Mobile Clinic was clean.
b. The atmosphere of the Mobile Clinic made me feel welcome.
c. I am satisfied with the help given to me by the staff on how to manage my own health after my visit to the clinic.

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* If the Mobile Clinic was not available today, I would have gone for care at:

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* If the Mobile Clinic was not available today, to see a health care provider I would have had to travel (one way):

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* I consider the Mobile Clinic to be my "home clinic"
(the clinic I plan to usually go to for primary care).

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* Covid-19 Related Questions
(If the question does not apply, leave blank)

  Strongly Agree Agree Disagree Strongly Disagree
a. My virtual appointment met my needs and was valuable.

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* Covid-19 Related Questions
(If the question does not apply, leave blank)

  Virtually In Person Either
b. In the future would you prefer to be seen virtually or in person?
Demographics:   (of the patient/client)

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* Gender:

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* Ethnicity (race):

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* Age:

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* Comments:

Mobile Clinic Patient Advisor Volunteers Needed!!  Someone just like you helped to design this survey! 
We want to partner with existing Mobile Clinic patients who might be interested in helping us review, design or provide feedback to our services. 
If you are interested in this, please leave your name, phone number and email address in the boxes below:

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* Volunteer Contact Information:


Forward additional Concerns or Compliments regarding your care to Patient Relations.

Patient Relations:  email  patientrelations@pmh-mb.ca or call  1-800-735-6596

Thank you for your participation!

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