Patient Satisfaction Survey

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* 1. What language do you mainly speak at home?

English

Spanish

Portuguese

Portuguese (Brazil)

Russian

Capeverdean Creole

Hatian Creole

French

Self-Identify

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* 2. What is your age?

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* 3. Your Gender

male

female

transgender

Self-Identify

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* 4. What is your Race/Ethnicity?

Asian

Pacific Islander

Black/African American

White (non-Hispanic)

American Indian/Alaska Native

Hispanic or Latino

Self-Identify

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* 5. What department were you seen in today?

Same Day Care

Managed Care (Health Insurance Assistance)

Pediatrics

Adult/Family

Medical Records

Adult Dental

Pediatric Dental

Lab

Physical Therapy

Eye Services

Other (please specify)

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* 6. How would you describe your interaction with your provider(s) today?

Warm and friendly

Rushed and distracted

Professional

Cold and not compassionate

Confused and uncertain

Other (please specify)

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* 7. When you are sick, how long to you have to wait for an appointment?

Same day

Next day

2-5 days

More than a week

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* 8. Please mark how we are doing in the following areas:

	Always	Usually	Sometimes	Never
Do you feel included in making decisions about your health care and treatment plans?	Do you feel included in making decisions about your health care and treatment plans? Always	Do you feel included in making decisions about your health care and treatment plans? Usually	Do you feel included in making decisions about your health care and treatment plans? Sometimes	Do you feel included in making decisions about your health care and treatment plans? Never
Other (please specify)
In the last 12 months, how often did your provider explain things in a way that was easy to understand?	In the last 12 months, how often did your provider explain things in a way that was easy to understand? Always	In the last 12 months, how often did your provider explain things in a way that was easy to understand? Usually	In the last 12 months, how often did your provider explain things in a way that was easy to understand? Sometimes	In the last 12 months, how often did your provider explain things in a way that was easy to understand? Never
Other (please specify)
Do you feel that the health center often schedules your specialist referrals in an efficient manner?	Do you feel that the health center often schedules your specialist referrals in an efficient manner? Always	Do you feel that the health center often schedules your specialist referrals in an efficient manner? Usually	Do you feel that the health center often schedules your specialist referrals in an efficient manner? Sometimes	Do you feel that the health center often schedules your specialist referrals in an efficient manner? Never
Other (please specify)
Do you feel that your culture, values and beliefs are respected by the provdiers and staff at the health center?	Do you feel that your culture, values and beliefs are respected by the provdiers and staff at the health center? Always	Do you feel that your culture, values and beliefs are respected by the provdiers and staff at the health center? Usually	Do you feel that your culture, values and beliefs are respected by the provdiers and staff at the health center? Sometimes	Do you feel that your culture, values and beliefs are respected by the provdiers and staff at the health center? Never
Other (please specify)
The nurses and Medical Assistants are friendly and helpful and and answer questions	The nurses and Medical Assistants are friendly and helpful and and answer questions Always	The nurses and Medical Assistants are friendly and helpful and and answer questions Usually	The nurses and Medical Assistants are friendly and helpful and and answer questions Sometimes	The nurses and Medical Assistants are friendly and helpful and and answer questions Never
Other (please specify)
Do you feel that you are able to leave your appointment with information regarding your visit?	Do you feel that you are able to leave your appointment with information regarding your visit? Always	Do you feel that you are able to leave your appointment with information regarding your visit? Usually	Do you feel that you are able to leave your appointment with information regarding your visit? Sometimes	Do you feel that you are able to leave your appointment with information regarding your visit? Never
Other (please specify)
How often are you given a list of your current medications when you leave the health center?	How often are you given a list of your current medications when you leave the health center? Always	How often are you given a list of your current medications when you leave the health center? Usually	How often are you given a list of your current medications when you leave the health center? Sometimes	How often are you given a list of your current medications when you leave the health center? Never
Other (please specify)
How often do you feel that it is easy to schedule your appointment over the phone?	How often do you feel that it is easy to schedule your appointment over the phone? Always	How often do you feel that it is easy to schedule your appointment over the phone? Usually	How often do you feel that it is easy to schedule your appointment over the phone? Sometimes	How often do you feel that it is easy to schedule your appointment over the phone? Never
Other (please specify)
Do you feel that the check in and check out staff are friendly and helpful when you come to the health center?	Do you feel that the check in and check out staff are friendly and helpful when you come to the health center? Always	Do you feel that the check in and check out staff are friendly and helpful when you come to the health center? Usually	Do you feel that the check in and check out staff are friendly and helpful when you come to the health center? Sometimes	Do you feel that the check in and check out staff are friendly and helpful when you come to the health center? Never
Other (please specify)
Do you feel that your time spent in the waiting room or waiting for the provider is acceptable?	Do you feel that your time spent in the waiting room or waiting for the provider is acceptable? Always	Do you feel that your time spent in the waiting room or waiting for the provider is acceptable? Usually	Do you feel that your time spent in the waiting room or waiting for the provider is acceptable? Sometimes	Do you feel that your time spent in the waiting room or waiting for the provider is acceptable? Never
Other (please specify)

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* 9. Tell us:

What do you like best about the health center?

What do you like least about the health center?

Do you have suggestions for improvement?

Would you like to be contacted about your experience?

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* 10. Please feel free to leave your contact information with us if you would like to be followed up with about your experience.

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number