Patient Satisfaction Survey

Your Privacy is Protected. All information that would let someone identify you or your family will be kept private. A Family Healing Center will not share your personal information with anyone without your approval. Your responses to this survey are also completely confidential.

Your Participation helps A Family Healing Center to maintain our primary care home status, which allows us to remain your PCP or primary care provider.

Patient Satisfaction Survey

Version 3.0
  • Survey Instructions

    Answer each question by marking the box to the left of your answer. You may be asked to skip some questions in this survey. When this happens, you will see a note that tells you what question to answer next.
  • Date Format: MM slash DD slash YYYY
  • The questions in this survey will refer to the provider named above as “this provider.” Please think of that person as you answer the survey.
  • Your Provider

  • Our records show that you've received care from this provider named above in the last 6 months.
  • Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?
  • How long have you been going to this provider?
  • Your Care From This Provider in the Last 6 Months

    These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.
  • In the last 6 months, how many times did you visit this provider to get care for yourself?
  • In the last 6 months, did you contact this provider’s office to get an appointment for an illness, injury, or condition that needed care right away?
  • In the last 6 months, when you contacted 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?
  • In the last 6 months, did you make any appointments for a check-up or routine care with this provider?
  • In the last 6 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?
  • In the last 6 months, did you make any appointments for a check-up or routine care with this provider?
  • In the last 6 months, when you contacted this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?
  • In the last 6 months, how often did this provider explain things in a way that was easy to understand?
  • In the last 6 months, how often did this provider listen carefully to you?
  • In the last 6 months, how often did this provider seem to know the important information about your medical history?
  • In the last 6 months, how often did this provider show respect for what you had to say?
  • In the last 6 months, how often did this provider spend enough time with you?
  • In the last 6 months, did this provider order a blood test, x-ray, or other test for you?
  • In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?
  • 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 6 months, did you take any prescription medicine?
  • In the last 6 months, how often did you and someone from this provider’s office talk about all the prescription medicines you were taking?
  • Clerks and Receptionists at This Provider’s Office

  • In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be?
  • In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect?
  • About You

  • In general, how would you rate your overall health?
  • In general, how would you rate your overall mental or emotional health?
  • What is your age?
  • Are you male or female?
  • What is the highest grade or level of school that you have completed?
  • Are you of Hispanic or Latino origin or descent?
  • What is your race? Mark one or more.
  • Did someone help you complete this survey?
  • If Yes. How did that person help you? Mark one or more.
  • Thank you.