CAHPS® Visit Survey 2.0 Template
Our Children's Clinic Patient Satisfaction Survey
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
2.
In the last 12 months, did you phone your healthcare provider’s office to get an appointment for an illness, injury, or condition that needed care right away?
Yes
No
3.
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
4.
In the last 12 months, did you make any appointments for a check-up or routine care with your healthcare provider?
Yes
No
5.
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
6.
In the last 12 months, did you phone your healthcare provider’s office with a medical question during regular office hours?
Yes
No
7.
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
8.
During your most recent visit, did your healthcare provider explain things in a way that was easy to understand?
Yes, definitely
Yes, somewhat
No
9.
During your most recent visit, did your healthcare provider listen carefully to you?
Yes, definitely
Yes, somewhat
No
10.
During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you?
Yes
No
11.
Did someone from your healthcare provider’s office follow up to give you those results?
Yes
No
12.
During your most recent visit, were clerks and receptionists at your healthcare provider’s office as helpful as you thought they should be?
Yes, definitely
Yes, somewhat
No
13.
What is your race? Mark one or more.
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other
14.
Did someone help you complete this survey?
Yes
No
15.
How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way