CAHPS® Visit Survey 2.0 Template
1.
Our records show that you got care from your healthcare provider. Is that right?
Yes
No
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
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
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
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
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
7.
In the last 12 months, did you make any appointments for a check-up or routine care with your healthcare provider?
Yes
No
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
9.
In the last 12 months, did you phone your healthcare provider’s office with a medical question during regular office hours?
Yes
No
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
11.
In the last 12 months, did you phone your healthcare provider’s office with a medical question after regular office hours?
Yes
No
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
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
14.
How long has it been since your most recent visit with your healthcare provider?
Less than 1 month
At least 1 month but less than 3 months
At least 3 months but less than 6 months
At least 6 months but less than 12 months
12 months or more
15.
Wait time includes time spent in the waiting room and exam room. During your most recent visit, did you see your healthcare provider within 15 minutes of your appointment time?
Yes
No
16.
During your most recent visit, did your healthcare provider explain things in a way that was easy to understand?
Yes, definitely
Yes, somewhat
No
17.
During your most recent visit, did your healthcare provider listen carefully to you?
Yes, definitely
Yes, somewhat
No
18.
During your most recent visit, did you talk with your healthcare provider about any health questions or concerns?
Yes
No
19.
During your most recent visit, did your healthcare provider give you easy to understand information about these health questions or concerns?
Yes, definitely
Yes, somewhat
No
20.
During your most recent visit, did your healthcare provider seem to know the important information about your medical history?
Yes, definitely
Yes, somewhat
No
21.
During your most recent visit, did your healthcare provider show respect for what you had to say?
Yes, definitely
Yes, somewhat
No
22.
During your most recent visit, did your healthcare provider spend enough time with you?
Yes, definitely
Yes, somewhat
No
23.
During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you?
Yes
No
24.
Did someone from your healthcare provider’s office follow up to give you those results?
Yes
No
25.
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
26.
Would you recommend your healthcare provider’s office to your family and friends?
Yes, definitely
Yes, somewhat
No
27.
During your most recent visit, were clerks and receptionists at your healthcare provider’s office as helpful as you thought they should be?
Yes, definitely
Yes, somewhat
No
28.
During your most recent visit, did clerks and receptionists at your healthcare provider’s office treat you with courtesy and respect?
Yes, definitely
Yes, somewhat
No
29.
In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
30.
In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
31.
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
32.
Are you male or female?
Male
Female
33.
What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
34.
Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
35.
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
36.
Did someone help you complete this survey?
Yes
No
37.
How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Current Progress,
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