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English (US)
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Patient Information
What is your age?
What is your gender?
What is your ethnicity?
How often do you use medical service/medication, etc?
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About Service: Rating/ scale
Ease of making appointment/obtaining service
5
4
3
2
1
N/A
Appointment/service available within a reasonable amount of time
5
4
3
2
1
N/A
Getting care as soon as you wanted it
5
4
3
2
1
N/A
Length of time waiting
5
4
3
2
1
N/A
Ability to get medical care when clinic/center is closed
5
4
3
2
1
N/A
Ease of getting referral if needed
5
4
3
2
1
N/A
Ease in getting follow up information/care
5
4
3
2
1
N/A
Overall experience
5
4
3
2
1
N/A
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About care providers
The friendliness and courtesy of the receptionist
5
4
3
2
1
N/A
The care and respect of healthcare staff
5
4
3
2
1
N/A
Did the healthcare practitioner listen carefully to your concern/questions
5
4
3
2
1
N/A
Were the instructions given to you clear and easy to understand
5
4
3
2
1
N/A
The professionalism of the staff
5
4
3
2
1
N/A
The overall quality of care you received during your visit
5
4
3
2
1
N/A
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About communication
Were your medical condition, treatment options, and potential risks explained to you in a way you could understand?
5
4
3
2
1
N/A
Did you receive adequate information on lifestyle changes or self-care related to your condition?
5
4
3
2
1
N/A
How satisfied are you with the communication and information provided by the healthcare team?
5
4
3
2
1
N/A
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