BIRTH AND WOMEN'S CARE PATIENT SATISFACTION SURVEY * 1. Our records show that you got care from Birth and Women's Care. Is that right? Yes No * 2. Who did you see at your most recent visit? Hall Helton Sharp * 3. How long have you been going to Birth and Women's Care? Less than 6 months At least 6 months but less than 1 year At least 1 year but less than 3 years At least 3 years but less than 5 years 5 years or more * 4. In the last 12 months, did you phone Birth and Women's Care’s office to get an appointment for an illness, injury, or condition that needed care right away? Yes No * 5. In the last 12 months, when you phoned Birth and Women's Care’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 * 6. In the last 12 months, when you made an appointment for a check-up or routine care with Birth and Women's Care, how often did you get an appointment as soon as you needed? Never Sometimes Usually Always * 7. 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 * 8. What is the highest grade or level of school that you have completed? 8th grade or less Some high school, but did not graduate High school graduate or GED Some college or 2-year degree 4-year college graduate More than 4-year college degree * 9. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see Birth and Women's Care within 15 minutes of your appointment time? Never Sometimes Usually Always * 10. Using any number from 0 to 10, where 0 is the worst patient portal experience and 10 being the best patient portal experience how do you rate the Patient Portal for ease of use? 10 Very Easy 9 8 7 6 5 4 3 2 1 0 Very Difficult 10 Very Easy 9 8 7 6 5 4 3 2 1 0 Very Difficult * 11. Have you used the Patient Portal to request a medication or medication refill? Yes No * 12. Have you used the Patient Portal to send a message to the office or clinical staff? Yes No * 13. In the last 12 months, did you phone Birth and Women's Care’s office with a medical question during regular office hours? Yes No N/A * 14. In the last 12 months, when you phoned Birth and Women's Care's office during regular office hours, how often did you get an answer to your medical question that same day? Never Sometimes Usually Always N/A * 15. In the last 12 months, did you phone Birth and Women's Care’s office with a medical question after regular office hours? Yes No * 16. In the last 12 months, when you phoned Birth and Women's Care’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 * 17. How long has it been since your most recent visit with Birth and Women's Care? Less than 1 month At least 1 month but less than 3 months At least 3 months but less than 6 months At least 6 months but less than 12 months 12 months or more * 18. During your most recent visit, did your healthcare provider explain things in a way that was easy to understand? Yes, definitely Yes, somewhat No * 19. During your most recent visit, did your healthcare provider listen carefully to you? Yes, definitely Yes, somewhat No * 20. During your most recent visit, did your healthcare provider seem to know the important information about your medical history? Yes, definitely Yes, somewhat No * 21. During your most recent visit, did your healthcare provider show respect for what you had to say? Yes, definitely Yes, somewhat No * 22. During your most recent visit, did your healthcare provider spend enough time with you? Yes, definitely Yes, somewhat No * 23. During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you? Yes No * 24. During your most recent visit, were clerks and receptionists at Birth and Women's Care’s office as helpful as you thought they should be? Yes, definitely Yes, somewhat No * 25. In the last 12 months, how many times did you visit Birth and Women's Care? None 1 time 2 3 4 5 to 9 10 or more times * 26. Have you used the Patient Portal to review your medical information or lab results Yes No * 27. Did someone from Birth and Women's Care’s office follow up to give you those results? Yes No N/A * 28. 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 * 29. Are you of Hispanic or Latino origin or descent? Yes, Hispanic or Latino No, not Hispanic or Latino * 30. 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 * 31. Using any number from 0 to 10, where 0 is the worst experience possible and 10 is the best experience possible, what number would you use to rate Birth and Women's Care coordination of any referrals you required? 10 Best experience possible 9 8 7 6 5 4 3 2 1 0 Worst experience possible . . 10 Best experience possible . 9 . 8 . 7 . 6 . 5 . 4 . 3 . 2 . 1 . 0 Worst experience possible * 32. Would you recommend Birth and Women's Care’s office to your family and friends? Yes, definitely Yes, somewhat No * 33. Using any number from 0 to 10, where 0 is the worst experience possible and 10 is the best experience possible, what number would you use to rate Birth and Women's Care? 10 Best experience possible 9 8 7 6 5 4 3 2 1 0 Worst experience possible . . 10 Best experience possible . 9 . 8 . 7 . 6 . 5 . 4 . 3 . 2 . 1 . 0 Worst experience possible Done
