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Community Health Service Agency, Inc.... Your Medical Home.
Patient Experience Questions
Please complete the survey about your most recent visit to a CHSA health center. Thank you for your participation.
*
1.
Is the appointment you are reviewing today within the last -
(Required.)
Week
Month
Several months
Year
More than a year
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2.
When you called to schedule an appointment to be seen right away, when were you seen?
(Required.)
Same day
1 day
2 to 3 days
4 to 7 days
More than 7 days
Don't know, no answer
Other (please specify)
*
3.
How often did this provider explain things in a way that was easy to understand?
(Required.)
Never
Sometimes
Usually
Always
Don't know, no answer
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4.
Did anyone in this provider's office talk with you about specific goals for your health?
(Required.)
Yes
No
Don't know, no answer
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5.
Did you see a specialist for a particular health problem? Specialists are doctors like surgeons, heart doctors, OB-GYNs, allergy doctors, skin doctors, and other doctors who specialize in one area of health care.
(Required.)
Yes
No, If no- skip the next question--
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6.
How often did your provider seem informed and up-to-date about the care you got from the specialists?
(Required.)
Never
Sometimes
Usually
Always
Don't know, no answer
Not applicable
*
7.
Would you recommend this health center to someone else?
(Required.)
Yes
No
Please describe why:
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8.
How did you hear about the health center?
(Required.)
A relative or friend
Flyer or other printed materials
Announcements on the radio or television
School
Church
Social Media (e.g. Facebook)
None of the above, I came here because I knew the provider was at this location
Don't know, no answer
Or another source
If you answered another source please describe:
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9.
How was your experience when you
called
your health center? (1 being the worst and 10 being the best)
(Required.)
1
2
3
4
5
6
7
8
9
10
To help improve your experience, please describe why you chose your rating.
*
10.
Do you consider yourself White, Black or African American, Hispanic or Latino, Asian or some other race-ethnic group?
(Required.)
White or Caucasian
Black or African American
Hispanic or Latino
Asian
Refused
Other race- ethnic group
If you answered other race- ethnic group, please describe:
*
11.
Indicate below your Primary Care Provider (PCP) at your health center. If you cannot remember your PCP's name, please list the location where you were seen.
(Required.)
12.
Any other comments you would like to share about the health center?