Beamsville Medical Centre
Family Health Team
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Evaluate Us
Comments/Feedback
Survey
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Survey
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?
I am completing this survey for myself
I am completing this survey for another person
B) If you are completing this survey for someone else, who are you completing it for?
*
...
I am completing this for a family member or friend
I am completing this for the patient or client
Other
1) How was the appointment for your most recent visit made?
*
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I didn't have an appointment- I just dropped-in (SKIP TO QUESTION 2B
I called and set it up
I emailed and set it up
I set it up at my last visit
You called me to set it up
Other
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?
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...
Excellent
Very Good
Good
Fair
Poor
2B) Thinking about your most recent visit, on a scale of poor to excellent, how would you rate your overall experience accessing the centre?
Excellent
Very Good
Good
Fair
Poor
3A) On a scale of poor to excellent, how would you rate the length of time you had to wait in reception/waiting area?
Excellent
Very Good
Good
Fair
Poor
3B) On a scale of poor to excellent, how would you rate your overall experience with our reception staff?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
5A) Thinking about your most recent visit, on a scale of poor to excellent, how would you rate the overall cleanliness of the centre?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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?
Excellent
Very Good
Good
Fair
Poor
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?
Yes
No
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?
Same day
Next Day
2-19 days
20 or more days
Not applicable (don't know/refused)
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?
Always
Often
Sometimes
Rarely
Never
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?
Always
Often
Sometimes
Rarely
Never
7C) When you see your doctor or nurse practitioner, how often do they or someone else in the office spend enough time with you?
Always
Often
Sometimes
Rarely
Never
8) Over the last year or so… Did you receive care from a health care provider(s) at a location other than this one?
Yes (Go to Q9)
No (Go to Q10)
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?
Always
Often
Sometimes
Rarely
Never
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?
Always
Often
Sometimes
Rarely
Never
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?
Always
Often
Sometimes
Rarely
Never
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?
Always
Often
Sometimes
Rarely
Never
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?
Very Easy
Somewhat Easy
Somewhat Difficult
Very DIfficult
Not Applicable
11) In general how would you rate your overall health?
Excellent
Very Good
Good
Fair
Poor
12) How long have you been visiting us for your health care?
Less than six months
Between six months and a year
Between one and three years
Between three and five years
Longer than five years
13) Using your best guess, how many times did you visit us over the last year or so for your own medical care?
One
Two
Three
Four
Five or more
Would you recommend our services to your family or friends?
Definitely yes
Probably yes
Probably no
Definitely no
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
Evaluate Us
Comments/Feedback
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4279 Hixon St., Beamsville, ON L0R 1B0
Phone: 905-563-5315 · After Hours: 1-866-553-7205
Mon-Thurs 8:30am - 8:00pm, Fri 8:30am-5:00pm
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