Patient Feedback Survey

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1. Are you/family/caregiver able to see your doctor when you need to? *

2. Can you/family/caregiver be seen on the same day if you call for an appointment? *

3. Do you/family/caregiver know that there is a phone number that you can call to receive medical advice from the doctor after regular business hours? *

4. When you/family/caregiver call your doctor with a medical question, do you get an answer on that same day? *

5. The practice space is clean and inviting? *

Communication

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6. Does your doctor explain things in a way that is easy to understand? *

7. Does your doctor talk with you about the medications you are taking at each visit? *

8. Are medical staff friendly and helpful? *

Coordination

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9. When blood tests, x-rays, or other tests are ordered, does the practice give you the results? *

10. If you/family/caregiver have received care from a specialist, does your doctor seem to know about the care you received? *

Self-Management Support

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11. Does your doctor provide information on ways to improve your health? *

12. Has your doctor asked if there are things that make it hard for you to take care of your health? *

13. Have staff at the practice recommended services in your community or offered their own workshops to help improve your health (i.e., weight management groups, nutrition/meal support)? *

14. Are recommendations to you/family/caregiver received (including community service and supports) to improve your health helpful? *

Continued

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15. What is your preferred method of communication? *

16. How do you consider the waiting time? *

17. Do you prefer appointments during the morning, afternoon, evening, or weekends? *

18. Which weeknight would you prefer extended hours? *

Patient Feedback

How would you rate your overall experience?