Patient Experience Survey

Thank you for your time.

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous.

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* 1. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

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* 2. What is your gender?

Female

Male

Transgender

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* 3. Your Race/Ethnicity (Check all that apply):

Asian

Pacific Islander

Black / African American

Native American / Alaska Native

White (Not Hispanic or Latino)

Hispanic or Latino (All Races)

Unkonwn

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* 4. Ease of getting care:

	POOR	FAIR	OK	GOOD	GREAT
Ability to get in to be seen	Ability to get in to be seen POOR	Ability to get in to be seen FAIR	Ability to get in to be seen OK	Ability to get in to be seen GOOD	Ability to get in to be seen GREAT
Hours the clinic is open	Hours the clinic is open POOR	Hours the clinic is open FAIR	Hours the clinic is open OK	Hours the clinic is open GOOD	Hours the clinic is open GREAT
Location of the clinic	Location of the clinic POOR	Location of the clinic FAIR	Location of the clinic OK	Location of the clinic GOOD	Location of the clinic GREAT
Prompt return of calls	Prompt return of calls POOR	Prompt return of calls FAIR	Prompt return of calls OK	Prompt return of calls GOOD	Prompt return of calls GREAT

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* 5. Waiting:

	POOR	FAIR	OK	GOOD	GREAT
Time in waiting room	Time in waiting room POOR	Time in waiting room FAIR	Time in waiting room OK	Time in waiting room GOOD	Time in waiting room GREAT
Time in exam room	Time in exam room POOR	Time in exam room FAIR	Time in exam room OK	Time in exam room GOOD	Time in exam room GREAT
Waiting for tests to be performed	Waiting for tests to be performed POOR	Waiting for tests to be performed FAIR	Waiting for tests to be performed OK	Waiting for tests to be performed GOOD	Waiting for tests to be performed GREAT
Waiting for test results	Waiting for test results POOR	Waiting for test results FAIR	Waiting for test results OK	Waiting for test results GOOD	Waiting for test results GREAT

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* 6. Provider: (Physician, Dentist, Physician Assistant, Nurse Practitioner)

	POOR	FAIR	OK	GOOD	GREAT
Listens to you	Listens to you POOR	Listens to you FAIR	Listens to you OK	Listens to you GOOD	Listens to you GREAT
Takes enough time with you	Takes enough time with you POOR	Takes enough time with you FAIR	Takes enough time with you OK	Takes enough time with you GOOD	Takes enough time with you GREAT
Explains what you want to know	Explains what you want to know POOR	Explains what you want to know FAIR	Explains what you want to know OK	Explains what you want to know GOOD	Explains what you want to know GREAT
Gives you good advice and treatment	Gives you good advice and treatment POOR	Gives you good advice and treatment FAIR	Gives you good advice and treatment OK	Gives you good advice and treatment GOOD	Gives you good advice and treatment GREAT

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* 7. Staff:

	POOR	FAIR	OK	GOOD	GREAT
Friendly and helpful	Friendly and helpful POOR	Friendly and helpful FAIR	Friendly and helpful OK	Friendly and helpful GOOD	Friendly and helpful GREAT
Answers your questions	Answers your questions POOR	Answers your questions FAIR	Answers your questions OK	Answers your questions GOOD	Answers your questions GREAT

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* 8. Payment:

	POOR	FAIR	OK	GOOD	GREAT
What you pay	What you pay POOR	What you pay FAIR	What you pay OK	What you pay GOOD	What you pay GREAT
Explanation of charges	Explanation of charges POOR	Explanation of charges FAIR	Explanation of charges OK	Explanation of charges GOOD	Explanation of charges GREAT
Collection of payment/money	Collection of payment/money POOR	Collection of payment/money FAIR	Collection of payment/money OK	Collection of payment/money GOOD	Collection of payment/money GREAT

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* 9. Facility:

	POOR	FAIR	OK	GOOD	GREAT
Neat and clean building	Neat and clean building POOR	Neat and clean building FAIR	Neat and clean building OK	Neat and clean building GOOD	Neat and clean building GREAT
Ease of finding where to go	Ease of finding where to go POOR	Ease of finding where to go FAIR	Ease of finding where to go OK	Ease of finding where to go GOOD	Ease of finding where to go GREAT
Comfort and safety while waiting	Comfort and safety while waiting POOR	Comfort and safety while waiting FAIR	Comfort and safety while waiting OK	Comfort and safety while waiting GOOD	Comfort and safety while waiting GREAT
Privacy	Privacy POOR	Privacy FAIR	Privacy OK	Privacy GOOD	Privacy GREAT

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* 10. Confidentiality:

	POOR	FAIR	OK	GOOD	GREAT
Keeping my personal information private	Keeping my personal information private POOR	Keeping my personal information private FAIR	Keeping my personal information private OK	Keeping my personal information private GOOD	Keeping my personal information private GREAT

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* 11. Overall:

	POOR	FAIR	OK	GOOD	GREAT
Likelihood of referring friends or relatives to the clinic:	Likelihood of referring friends or relatives to the clinic: POOR	Likelihood of referring friends or relatives to the clinic: FAIR	Likelihood of referring friends or relatives to the clinic: OK	Likelihood of referring friends or relatives to the clinic: GOOD	Likelihood of referring friends or relatives to the clinic: GREAT
Your likelihood of returning for care:	Your likelihood of returning for care: POOR	Your likelihood of returning for care: FAIR	Your likelihood of returning for care: OK	Your likelihood of returning for care: GOOD	Your likelihood of returning for care: GREAT

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* 12. Is Western Sierra Medical Clinic your regular source of care?

Yes

No

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* 13. What do you like best about the health center?

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* 14. What do you like least about the health center?

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* 15. Suggestions for improvement...