CAHPS® 12 Month Survey 2.0 (Adult) Template Durham Women's Clinic - Patient Experience Survey Tool Question Title * 1. Our records show that you got care from Durham Women's Clinic. Is that right? Yes No OK Question Title * 2. Is your healthcare provider, the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt? Yes No OK Question Title * 3. How long have you been going to your healthcare provider? Less than 6 months At least 6 months but less than 1 year At least 1 year but less than 3 years At least 3 years but less than 5 years 5 years or more OK Question Title * 4. In the last 12 months, how many times did you visit your healthcare provider? None 1 time 2 3 4 5 to 9 10 or more times OK Question Title * 5. In the last 12 months, did you phone your healthcare provider’s office to get an appointment for an illness, injury, or condition that needed care right away? Yes No OK Question Title * 6. In the last 12 months, when you phoned your healthcare provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed? Never Sometimes Usually Always OK Question Title * 7. In the last 12 months, did you make any appointments for a check-up or routine care with your healthcare provider? Yes No OK Question Title * 8. In the last 12 months, when you made an appointment for a check-up or routine care with your healthcare provider, how often did you get an appointment as soon as you needed? Never Sometimes Usually Always OK Question Title * 9. In the last 12 months, did you phone your healthcare provider’s office with a medical question during regular office hours? Yes No OK Question Title * 10. In the last 12 months, when you phoned your healthcare provider’s office during regular office hours, how often did you get an answer to your medical question that same day? Never Sometimes Usually Always OK Question Title * 11. In the last 12 months, did you phone your healthcare provider’s office with a medical question after regular office hours? Yes No OK Question Title * 12. In the last 12 months, when you phoned your healthcare provider’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed? Never Sometimes Usually Always OK Question Title * 13. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see your healthcare provider within 15 minutes of your appointment time? Never Sometimes Usually Always OK Question Title * 14. In the last 12 months, how often did your healthcare provider explain things in a way that was easy to understand? Never Sometimes Usually Always OK Question Title * 15. In the last 12 months, how often did your healthcare provider listen carefully to you? Never Sometimes Usually Always OK Question Title * 16. In the last 12 months, how often did your healthcare provider give you easy to understand information about these health questions or concerns? Never Sometimes Usually Always OK Question Title * 17. In the last 12 months, how often did your healthcare provider seem to know the important information about your medical history? Never Sometimes Usually Always OK Question Title * 18. In the last 12 months, how often did your healthcare provider show respect for what you had to say? Never Sometimes Usually Always OK Question Title * 19. In the last 12 months, how often did your healthcare provider spend enough time with you? Never Sometimes Usually Always OK Question Title * 20. In the last 12 months, did your healthcare provider order a blood test, x-ray, or other test for you? Yes No OK Question Title * 21. In the last 12 months, when your healthcare provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results? Never Sometimes Usually Always OK Question Title * 22. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate your healthcare provider? 10 Best provider possible 9 8 7 6 5 4 3 2 1 0 Worst provider possible . . 10 Best provider possible . 9 . 8 . 7 . 6 . 5 . 4 . 3 . 2 . 1 . 0 Worst provider possible OK Question Title * 23. In the last 12 months, how often were clerks and receptionists at your healthcare provider's office as helpful as you thought they should be? Never Sometimes Usually Always OK Question Title * 24. In the last 12 months, how often did clerks and receptionists at your healthcare provider's office treat you with courtesy and respect? Never Sometimes Usually Always OK Question Title * 25. In general, how would you rate your overall health? Excellent Very good Good Fair Poor OK Question Title * 26. In general, how would you rate your overall mental or emotional health? Excellent Very good Good Fair Poor OK Question Title * 27. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older OK Question Title * 28. What is your race? Mark one or more. White Black or African American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other OK DONE