CAHPS® Visit Survey 2.0 Template Question Title * 1. Our records show that you got care from your healthcare provider. Is that right? Yes No 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 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 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 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 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 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 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 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 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 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 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 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 Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 17. During your most recent visit, did your healthcare provider listen carefully to you? Yes, definitely Yes, somewhat No Question Title * 18. During your most recent visit, did you talk with your healthcare provider about any health questions or concerns? Yes No Question Title * 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 Question Title * 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 Question Title * 21. During your most recent visit, did your healthcare provider show respect for what you had to say? Yes, definitely Yes, somewhat No Question Title * 22. During your most recent visit, did your healthcare provider spend enough time with you? Yes, definitely Yes, somewhat No Question Title * 23. During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you? Yes No Question Title * 24. Did someone from your healthcare provider’s office follow up to give you those results? Yes No Question Title * 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 Question Title * 26. Would you recommend your healthcare provider’s office to your family and friends? Yes, definitely Yes, somewhat No Question Title * 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 Question Title * 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 Question Title * 29. In general, how would you rate your overall health? Excellent Very good Good Fair Poor Question Title * 30. In general, how would you rate your overall mental or emotional health? Excellent Very good Good Fair Poor Question Title * 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 Question Title * 32. Are you male or female? Male Female Question Title * 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 Question Title * 34. Are you of Hispanic or Latino origin or descent? Yes, Hispanic or Latino No, not Hispanic or Latino Question Title * 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 Question Title * 36. Did someone help you complete this survey? Yes No Question Title * 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 Done
