1.Which of the following is your primary care provider?

Dr Fournier

Dr Gauvin

Dr Papineau

Dr Shaheen

Dr Talbot-Lemaire

Mireille Fortin-Ukrainetz, NP

2.In the past 12 months, 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?

Never

Rarely

Sometimes

Often

Always

Not applicable

Never

Rarely

Sometimes

Often

Always

Not applicable

3.In the past 12 months, when you consulted an allied health provider at the Nord-Aski Family Health Team, did you feel you were sufficiently involved in the decisions regarding your healthcare? (Nurse, Mental Health Counsellor, Dietitian, Patient Navigator and First Nation Liaison)

Never

Rarely

Sometimes

Often

Always

Not Applicable

Never

Rarely

Sometimes

Often

Always

Not Applicable

4.How would you rate the following elements?

Poor

Fair

Good

Very Good

Excellent

Experience before your appointment (reception, wait time in reception or exam room, etc.)

Poor

Fair

Good

Very Good

Excellent

Experience during your appointment (feeling respected, understood, etc.)

Poor

Fair

Good

Very Good

Excellent

Experience after your appointment (follow-up, lab results, etc.)

Poor

Fair

Good

Very Good

Excellent

5.Please provide any additional comment in the box below:

6.I always feel comfortable and welcome at Nord-Aski Family Health Team

Yes

No

7.Overall, how would you rate your experience with our Physician Group or Family Health Team?

Very Good

Good

Fair

Poor 

Very poor