1. A health care provider can care for patients in person, by phone, or by video. Our records show that you got care from the provider named below in the last 6 months.
Name of provider label goes here
Is that right?
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?
3. How long have you been going to this provider?
4. In the last 6 months, how many times did you visit this provider to get care for yourself?
5. In the last 6 months, did you contact this provider's office to get an appointment for an illness, injury, or condition that needed care right away?
6. In the last 6 months, when you contacted this provider's office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
7. In the last 6 months, did you make any appointments for a check-up or routine care with this provider?
8. In the last 6 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?
9. In the last 6 months, did you contact this provider's office with a medical question during regular office hours?
10. 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?
11. In the last 6 months, how often did this provider explain things in a way that was easy to understand?
12. In the last 6 months, how often did this provider listen carefully to you?
13. In the last 6 months, how often did this provider seem to know the important information about your medical history?
14. In the last 6 months, how often did this provider show respect for what you had to say?
15. In the last 6 months, how often did this provider spend enough time with you?
16. In the last 6 months, did this provider order a blood text, x-ray, or other test for you?
17. In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider's office follow up to give you those results?
18. 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 this provider?
19. In the last 6 months, did you take any prescription medicine?
20. In the last 6 months, how often did you and someone from this provider's office talk about all the prescription medicines you were taking?
21. In the last 6 months, how often were clerks and receptionists at this provider's office as helpful as you thought they should be?
22. In the last 6 months, how often did clerks and receptionists at this provider's office treat you with courtesy and respect?
23. In general, how would you rate your overall health?
24. In general, how would you rate your overall mental or emotional health?
25. What is your age?
26. Are you male or female?
27. What is the highest grade or level of school that you have completed?
28. Are you of Hispanic or Latino origin or descent?
29. What is you race? Mark one or more.
30. In the last 6 months, were any of your visits with this provider...
31. Did someone help you complete this survey?
32. How did that person help you? Mark one or more.
