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* 1. During your most recent visit, which provider(s) did you see for your care?

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* 2. Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

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* 3. How long have you been going to this provider?

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* 4. In the last 6 months, when you contacted this provider's office during regular office hours, how often did you get an answer to your medical question that same day?

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* 5. How often were you able to schedule an appointment at your preferred availability?

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* 6. In the last 6 months, how often did this provider explain things in a way that was easy to understand?

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* 7. In the last 6 months, how often did this provider show respect for what you had to say?

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* 8. In the last 6 months, how often did this provider spend enough time with you?

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* 9. 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?

  0 Worst provider possible 1 2 3 4 5 6 7 8 9 10 Best provider possible
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* 10. Did someone talk with you about what you would like to fix or improve about your health?

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* 11. Did someone ask you about what makes it hard to take care of your health?

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* 12. Is there anything we could have done to improve your most recent visit?

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