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* 1. Our records show that you got care from Wayne Women's Clinic. Is that right?

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* 2. Is Wayne Women's Clinic 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 Wayne Women's Clinic?

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* 4. In the last 12 months, how many times did you visit Wayne Women's Clinic?

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* 5. In the last 12 months, did you phone Wayne Women's Clinic’s office to get an appointment for an illness, injury, or condition that needed care right away?

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* 6. In the last 12 months, when you phoned Wayne Women's Clinic’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

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* 7. In the last 12 months, did you make any appointments for a check-up or routine care with Wayne Women's Clinic?

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* 8. In the last 12 months, when you made an appointment for a check-up or routine care with Wayne Women's Clinic, how often did you get an appointment as soon as you needed?

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* 9. In the last 12 months, did you phone Wayne Women's Clinic’s office with a medical question during regular office hours?

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* 10. In the last 12 months, when you phoned Wayne Women's Clinic’s office during regular office hours, how often did you get an answer to your medical question that same day?

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* 11. In the last 12 months, did you phone Wayne Women's Clinic’s office with a medical question after regular office hours?

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* 12. In the last 12 months, when you phoned Wayne Women's Clinic’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?

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* 13. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see Wayne Women's Clinic within 15 minutes of your appointment time?

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* 14. How long has it been since your most recent visit with Wayne Women's Clinic?

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* 15. Wait time includes time spent in the waiting room and exam room. During your most recent visit, did you see Wayne Women's Clinic within 15 minutes of your appointment time?

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* 16. During your most recent visit, did Wayne Women's Clinic explain things in a way that was easy to understand?

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* 17. During your most recent visit, did Wayne Women's Clinic listen carefully to you?

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* 18. During your most recent visit, did you talk with Wayne Women's Clinic about any health questions or concerns?

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* 19. During your most recent visit, did Wayne Women's Clinic give you easy to understand information about these health questions or concerns?

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* 20. During your most recent visit, did Wayne Women's Clinic seem to know the important information about your medical history?

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* 21. During your most recent visit, did Wayne Women's Clinic show respect for what you had to say?

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* 22. During your most recent visit, did Wayne Women's Clinic spend enough time with you?

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* 23. During your most recent visit, did Wayne Women's Clinic order a blood test, x-ray, or other test for you?

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* 24. Did you receive notification of your test results from Wayne Women's Clinic?

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* 25. 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 Wayne Women's Clinic?

  10 Best provider possible 9 8 7 6 5 4 3 2 1 0 Worst provider possible
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* 26. Would you recommend Wayne Women's Clinic’s office to your family and friends?

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* 27. During your most recent visit, were clerks and receptionists at Wayne Women's Clinic’s office as helpful as you thought they should be?

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* 28. During your most recent visit, did clerks and receptionists at Wayne Women's Clinic’s office treat you with courtesy and respect?

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* 29. In general, how would you rate your overall health?

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* 30. In general, how would you rate your overall mental or emotional health?

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* 31. What is your age?

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* 32. Are you male or female?

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* 33. What is the highest grade or level of school that you have completed?

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* 34. Are you of Hispanic or Latino origin or descent?

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* 35. What is your race? Mark one or more.

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* 36. Did someone help you complete this survey?

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* 37. How did that person help you? Mark one or more.

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* 38. What is your primary insurance carrier?

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* 39. How would you rate your experience with the clinical staff (RN, LPN, MA) who assisted you prior to your actual encounter with the provider?

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