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* 1. Our records show that you got care from your healthcare provider. Is that right?

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* 2. 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?

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* 3. During your most recent visit, did your healthcare provider explain things in a way that was easy to understand?

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* 4. During your most recent visit, did you talk with your healthcare provider about any health questions or concerns?

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* 5. During your most recent visit, did your healthcare provider give you easy to understand information about these health questions or concerns?

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* 6. Would you recommend your healthcare provider’s office to your family and friends?

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* 7. During your most recent visit, were clerks and receptionists at your healthcare provider’s office as helpful as you thought they should be?

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* 8. During your most recent visit, did clerks and receptionists at your healthcare provider’s office treat you with courtesy and respect?

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* 9. Are you male or female?

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* 10. How friendly is your doctor's office staff?

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* 11. How helpful is your doctor at explaining your medical condition(s)?

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* 12. How likely are you to recommend your doctor to family or friends?

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* 13. In general, if there was an extended wait time to see your doctor, how often was an explanation provided to you?

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* 14. How polite are the staff at your doctor's to you?

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* 15. How easy is it to schedule urgent appointments with your doctor when you're ill?

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