* 1. Which provider did you see today?

* 2. I am able to get through to the office on the phone during office hours

* 3. In the last 12 months, when you phoned your behavioral health provider’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?

* 4. How convenient was the appointment time you were able to get?

* 5. How easy is it to schedule urgent appointments with your provider?

* 6. How courteous and helpful was the receptionist when you arrived at our office?

* 7. How friendly was the clinical staff during your visit?

* 8. Overall, how often do you wait more than 15 minutes to see your provider? (Wait time includes time spent in the waiting room and exam room.)

* 9. How satisfied or dissatisfied were you with the amount of time your provider spent with you addressing your needs?

* 10. Were your needs met at this visit?

* 11. Did anyone talk to you about the medication you take?

* 12. Did your provider talk to you about your health goals?

* 13. Were you asked if you had visits with other health care providers since your last visit?

* 14. Did anyone help you make an appointment with a specialty provider if necessary?

* 15. Have we ever given you information about FMC being your medical home?

* 16. Have we ever helped you find other community resources you might need that FMC does not provide?

* 17. Do you feel what you pay for your care is reasonable?

* 18. May we contact you for further input regarding your cost of care?

* 19. Would you recommend FMC to your friends and family?

* 20. Do you have any comments or suggestions?

* 21. What is your race?

* 22. What is your ethnicity? (Please select all that apply.)

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