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?
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?
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?
4.In the last 12 months, did you make any appointments for a check-up or routine care with your healthcare provider?
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?
6.In the last 12 months, did you phone your healthcare provider’s office with a medical question during regular office hours?
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?
8.During your most recent visit, did your healthcare provider explain things in a way that was easy to understand?
9.During your most recent visit, did your healthcare provider listen carefully to you?
10.During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you?
11.Did someone from your healthcare provider’s office follow up to give you those results?
12.During your most recent visit, were clerks and receptionists at your healthcare provider’s office as helpful as you thought they should be?
13.What is your race? Mark one or more.
14.Did someone help you complete this survey?
15.How did that person help you? Mark one or more.