Health Care Professional Participant Feedback

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your email address?

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* 4. What is the name of your health care professional?

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* 5. During your most recent visit, did your health care professional listen carefully to you?

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* 6. During your most recent visit, did your health care professional seem to know the important information about your medical history?

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* 7. In the last 12 months, how often did your health care professional explain things in a way that was easy to understand?

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* 8. How likely is it that you would recommend your health care professional to a friend or family member?

Not at all likely
Extremely likely

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* 9. 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 health care professional?

  10 Best provider possible 9 8 7 6 5 4 3 2 1 0 Worst provider possible
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* 10. Do you have any other comments, questions, or concerns?

T