1. Visits with a health care provider can be in person, by phone, or by video. Our records show that you had a recent visit with the provider named below.
Name of provider label goes here
Is that right?
2. Is this the provider you usually talk to if you need a check-up, want advice about a health problem, or get sick or hurt?
3. How long has it been since your most recent in-person, phone, or video visit with this provider?
4. Was your most recent visit with this provider in person?
5. Was your most recent visit with this provider a video visit?
6. Did you need instructions from this provider's office about how to use video for this visit?
7. Did this provider's office give you all the instructions you needed to use video for this visit?
8. During your most recent visit, was the video easy to use?
9. Was your most recent visit with this provider by phone?
10. During your most recent visit, were you and this provider able to hear each other clearly?
11. Was your most recent visit for an illness, injury, or condition that needed care right away?
12. Was that recent visit as soon as you needed?
13. Did your most recent visit start on time?
14. During your most recent visit, did this provider explain things in a way that was easy to understand?
15. During your most recent visit, did this provider listen carefully to you?
16. During your most recent visit, did this provider show respect for what you had to say?
17. During your most recent visit, did this provider spend enough time with you?
18. During your most recent visit, did this provider have the medical information they needed about you?
19. During your most recent visit, did this provider order a blood test, x-ray, or other test for you?
20. Did someone from this provider's office follow up to give you those results?
21. Using any number from 0 to 10, where 0 is the worst visit possible and 10 is the best visit possible, what number would you use to rate your most recent visit?
22. Staff at a provider's office may talk with you about your visit, help set it up, and remind you about your appointment. Thinking about your most recent visit, did you talk to staff from this provider's office?
23. Thinking about your most recent visit, was the staff from this provider's office as helpful as you thought they should be?
24. Thinking about your most recent visit, did the staff from this provider's office treat you with courtesy and respect?
25. In general, how would you rate your overall health?
26. In general, how would you rate your overall mental or emotional health?
27. What is your age?
28. Are you male or female?
29. What is the highest grade or level of school that you have completed?
30. Are you of Hispanic or Latino origin or descent?
31. What is your race? Mark one or more.
32. Did someone help you complete this survey?
33. How did that person help you? Mark one or more.
