* 1. Which office did you visit?

* 2. Which Clinician did you see?

* 3. Is this the Clinician you prefer to see (your "assigned PCP")?

* 4. How long as you chid been a patient at Child and Adolescent Clinic?

* 5. Is your child here today for a sick / injury visit?

* 6. If YES for a sick / injury visit, when was the first appointment offered?

* 7. Did you call our office looking for medical advice during regular office hours?

* 8. If YES for medical advice, did you get an answer within 12 hours, either on the phone or left on your voicemail system?

* 9. Is your child here today for a well-child exam / routine checkup?

* 10. If YES for a well-child exam, when you scheduled, were you offered an appointment within 2 weeks?

* 11. Did the Clinician who saw your child today explain things about your child's health in a way that was easy to understand?

* 12. Did the Clinician who saw your child today seem informed and up-to-date about the care your child got from specialists outside our clinic?

* 13. Were the Receptionists as helpful, courteous, and respectful as you thought they should be?

* 14. Was the Medical Assistant (the person who escorted you to the exam room) as helpful, courteous, and respectful as you thought he/she should be?

* 15. Who was particularly helpful to you today?

* 16. Did you have enough opportunity to ask questions?

* 17. Did all of your questions get answered?

* 18. Did anyone offer to help make it easier to take care of your child's health?

* 19. If your child currently takes any prescription medications, did you and anyone in this Clinician's office talk about this prescription medications?

* 20. In the last 12 months, approximately how many times did this child visit any Clinician in this office?

* 21. Please rate this Clinician using any number from 0 to 10, where 0 is the worst Clinician possible and 10 is the best.

0 (worst)
i We adjusted the number you entered based on the slider’s scale.

* 22. What is the child's age who had an appointment with a Clinician today?

* 23. This child is covered by insurance through:

* 24. Have you used the online Patient Portal from home (through the CandAC website)?

* 25. If YES you have used the patient portal, what was useful?

* 26. What would make the Patient Portal more valuable for you?

* 27. Other comments: