* 1. 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?

* 2. In the last 12 months, when you phoned your healthcare provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

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

* 4. In the last 12 months, 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?

* 5. 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?

* 6. In the last 12 months, how often did your healthcare provider give you easy to understand information about these health questions or concerns?

* 7. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 6 months, how often did your provider seem informed and up-to-date about the care you got from specialists? 

* 8. Chronic illness is described as an on-going condition lasting usually 3+ months (such as diabetes, hypertension or asthma). In the last 12 months, how often did your provider or someone from the office give you self-management resources and/or tools to help you manage your chronic illness?

* 9. In the last 12 months, how often did someone from provider’s office talk with you about developing a plan of care and setting specific health goals?

* 10. In the last 12 months, when your 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?

* 11. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see your healthcare provider within 15 minutes of your appointment time?

* 12. In the last 12 months, how often did clerks and receptionists at your healthcare provider's office treat you with courtesy and respect?

* 13. Overall, how would you rate the service you received from the staff at our office?

* 14. 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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* 15. Is there anything we could have done to improve your last visit?

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