PCMH Survey

In the last 12 months, how many times did you visit this provider to get care for yourself?

None

1 time

2

3

4

5 to 9

10 or more times

In the last 12 months, did you phone this provider’s office to get an appointment for an illness, injury or condition that needed care right away?

Yes

No

. In the last 12 months, when you phoned this 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

In the last 12 months, how many days did you usually have to wait for an appointment when you needed care right away?

Did this provider’s office give you information about what to do if you needed care during evenings, weekends, or holidays?

Yes

No

Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see this provider within 15 minutes of your appointment time?

Never

Sometimes

Usually

Always

In the last 12 months, when this provider ordered a blood test, x‐ray, or other test for you, how often did someone from this provider’s office followup to give you those results?

Never

Sometimes

Usually

Always

How often do you conduct surveys?

Weekly

Monthly

Quarterly

Annually

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 this provider?

In the last 12 months, did anyone in this provider’s office talk with you about specific goals for your health?

Yes

No