CAHPS® 12 Month Survey 2.0 (Adult) Template Question Title * 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? Yes No Question Title * 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? Never Sometimes Usually Always Question Title * 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? Never Sometimes Usually Always Question Title * 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? Never Sometimes Usually Always Question Title * 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? Never Sometimes Usually Always Question Title * 6. In the last 12 months, how often did your healthcare provider give you easy to understand information about these health questions or concerns? Never Sometimes Usually Always Question Title * 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? Never Sometimes Usually Always Question Title * 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? Never Sometimes Usually Always Question Title * 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? Never Sometimes Usually Always Question Title * 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? Never Sometimes Usually Always Question Title * 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? Never Sometimes Usually Always Question Title * 12. In the last 12 months, how often did clerks and receptionists at your healthcare provider's office treat you with courtesy and respect? Never Sometimes Usually Always Question Title * 13. Overall, how would you rate the service you received from the staff at our office? Excellent Very good Good Fair Poor Question Title * 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 . . 10 Best provider possible . 9 . 8 . 7 . 6 . 5 . 4 . 3 . 2 . 1 . 0 Worst provider possible Question Title * 15. Is there anything we could have done to improve your last visit? Done