CAHPS® Visit Survey 2.0 Template Our Children's Clinic Patient Satisfaction Survey Question Title * 1. 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 * 2. 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 * 3. 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 * 4. 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 * 5. 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 * 6. 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 * 7. 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 * 8. During your most recent visit, did your healthcare provider explain things in a way that was easy to understand? Yes, definitely Yes, somewhat No OK Question Title * 9. During your most recent visit, did your healthcare provider listen carefully to you? Yes, definitely Yes, somewhat No OK Question Title * 10. During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you? Yes No OK Question Title * 11. Did someone from your healthcare provider’s office follow up to give you those results? Yes No OK Question Title * 12. 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 OK Question Title * 13. 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 Question Title * 14. Did someone help you complete this survey? Yes No OK Question Title * 15. 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 OK DONE