Survey

Please take a moment to evaluate us, so that we may better serve you.

A) Are you completing this survey for yourself or for another person?

B) If you are completing this survey for someone else, who are you completing it for? *

1) How was the appointment for your most recent visit made? *

2A) Thinking about your most recent visit, on a scale of poor to excellent, how would you rate the length of time it took between making your appointment and the visit you just had? *

2B) Thinking about your most recent visit, on a scale of poor to excellent, how would you rate your overall experience accessing the centre?
3A) On a scale of poor to excellent, how would you rate the length of time you had to wait in reception/waiting area?
3B) On a scale of poor to excellent, how would you rate your overall experience with our reception staff?

3C) On a scale of poor to excellent, how would you rate the length of time you had to wait in the examination room before you spoke with the health care provider about the reason for your visit?

4A) Thinking about the MAIN health care provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on knowing your medical history?

4B) Thinking about the MAIN health care provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on listening to your concerns?

4C) Thinking about the MAIN health care provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on speaking a language you could understand?

4D) Thinking about the MAIN health care provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on explaining things in a way that was easy to understand?

4E) Thinking about the MAIN health care provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on being sensitive to your needs and preferences?

4F) Thinking about the MAIN health care provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on treating you with dignity and respect?

4G) Thinking about the MAIN health care provider you spoke with during the visit, on a scale of poor to excellent, how would you rate them on giving you clear instructions about what you need to do after your visit

4H) Thinking about the MAIN health care provider you spoke with during the visit, on a scale of poor to excellent, how would you rate them on the reason for your visit?

5A) Thinking about your most recent visit, on a scale of poor to excellent, how would you rate the overall cleanliness of the centre?
5B) Thinking about your most recent visit, on a scale of poor to excellent, how would you rate the overall physical comfort of the centre?

5C) Thinking about your most recent visit, on a scale of poor to excellent, how would you rate your confidence in the doctor/health care provider(s) you saw during the visit?

5D) Thinking about your most recent visit, on a scale of poor to excellent, how would you rate your confidence that your health information was treated with the level of privacy you expect?

5E) Thinking about your most recent visit, on a scale of poor to excellent, how would you rate your overall experience with the visit you had with us?
6A) Thinking about the last year or so, the last time you were sick or were concerned you had a health problem, did you get an appointment on the date you wanted?

6B) Thinking about the last year or so, the last time you were sick or were concerned you had a health problem, how many days did it take from when you first tried to see your doctor or nurse practitioner to when you actually SAW him/her or someone else in their office?

7A) When you see your doctor or nurse practitioner, how often do they or someone else in the office give you an opportunity to ask questions about recommended treatment?

7B) When you see your doctor or nurse practitioner, how often do they or someone else in the office involve you as much as you want to be in decisions about your care and treatment?

7C) When you see your doctor or nurse practitioner, how often do they or someone else in the office spend enough time with you?
8) Over the last year or so… Did you receive care from a health care provider(s) at a location other than this one?

9A) Thinking about the health care(s) providers that you have seen at the different places you have received care over the last year or so, how often did each seem to know your medical history?

9B) Thinking about the health care(s) providers that you have seen at the different places you have received care over the last year or so, how often did each seem to have your recent tests or exam results?

9C) Thinking about the health care(s) providers that you have seen at the different places you have received care over the last year or so, how often were they consistent in what they were telling you about your care and treatment?

9D) Thinking about the health care(s) providers that you have seen at the different places you have received care over the last year or so, how often did they seem to work well together in caring for you?

10) On another issue, the last time when you needed medical care in the evening, on a weekend, or on a public holiday, how easy was it to get care without going to the emergency department?

11) In general how would you rate your overall health?

12) How long have you been visiting us for your health care?

13) Using your best guess, how many times did you visit us over the last year or so for your own medical care?
Would you recommend our services to your family or friends?
Thinking of your overall experience with our centre, what are two things done particularly well?
Thinking of your overall experience with our centre, what are two things that could be improved?
Is there any additional information or feedback you would like to share with us that could help us improve the way we provide care?

Please verify your response by typing in the word/print seen in the image

Survey

Survey

Please take a moment to evaluate us, so that we may better serve you.

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