Answer each question by checking the radio button next to your answer.

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Your Provider

1. Have you have received care from Dr. Winston G. Douglas within the last 12 months?(*)

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We apologize but this 12-Month Survey is ONLY for patients that have seen Dr. Douglas within the last 12 months. Thank you!

2. Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?(*)

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3. How long have you been going to this provider?(*)

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This survey will take approximately 8-12 minutes to complete.

Are you able to complete this survey now without any interruptions?(*)

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Please come back and take this survey when you can easily spend 8-12 minutes answering questions without any interruptions. Thank you!

 

Your Care From This Provider in the Last 12 Months

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

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5. 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?(*)

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6. 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?(*)

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

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8. In the last 12 months, did you make any appointments for a check-up or routine care with this provider?(*)

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9. In the last 12 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?(*)

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

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11. In the last 12 months, did you need care for yourself during evenings, weekends, or holidays?(*)

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12. In the last 12 months, how often were you able to get the care you needed from this provider’s office during evenings, weekends, or holidays?(*)

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13. In the last 12 months, did you phone this provider’s office with a medical question during regular office hours?(*)

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14. In the last 12 months, when you phoned this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?(*)

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15. In the last 12 months, did you phone this provider’s office with a medical question after regular office hours?(*)

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16. In the last 12 months, when you phoned this provider’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?(*)

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17. Some offices remind patients between visits about tests, treatment or appointments. In the last 12 months, did you get any reminders from this provider’s office between visits?(*)

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18. 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?(*)

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19. In the last 12 months, how often did this provider explain things in a way that was easy to understand?(*)

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20. In the last 12 months, how often did this provider listen carefully to you?(*)

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21. In the last 12 months, did you talk with this provider about any health questions or concerns?(*)

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22. In the last 12 months, how often did this provider give you easy to understand information about these health questions or concerns?(*)

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23. In the last 12 months, how often did this provider seem to know the important information about your medical history?(*)

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24. In the last 12 months, how often did this provider show respect for what you had to say?(*)

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25. In the last 12 months, how often did this provider spend enough time with you?(*)

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26. In the last 12 months, did this provider order a blood test, x-ray, or other test for you?(*)

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27. 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 follow up to give you those results?(*)

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28. In the last 12 months, did you and this provider talk about starting or stopping a prescription medicine?(*)

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29. When you talked about starting or stopping a prescription medicine, how much did this provider talk about the reasons you might want to take a medicine?(*)

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30. When you talked about starting or stopping a prescription medicine, how much did this provider talk about the reasons you might not want to take a medicine?(*)

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31. When you talked about starting or stopping a prescription medicine, did this provider ask you what you thought was best for you?(*)

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32. 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?(*)

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33. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 12 months, did you see a specialist for a particular health problem?(*)

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34. In the last 12 months, how often did the provider named in Question 1 seem informed and up-to-date about the care you got from specialists?(*)

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

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36. In the last 12 months, did anyone in this provider’s office ask you if there are things that make it hard for you to take care of your health?(*)

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37. In the last 12 months, did you take any prescription medicine?(*)

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38. In the last 12 months, did you and anyone in this provider’s office talk at each visit about all the prescription medicines you were taking?(*)

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39. In the last 12 months, did anyone in this provider’s office ask you if there was a period of time when you felt sad, empty, or depressed?(*)

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40. In the last 12 months, did you and anyone in this provider’s office talk about things in your life that worry you or cause you stress?(*)

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41. In the last 12 months, did you and anyone in this provider’s office talk about a personal problem, family problem, alcohol use, drug use, or a mental or emotional illness?(*)

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Clerks and Receptionists at This Provider’s Office

42. In the last 12 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be?(*)

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43. In the last 12 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect?(*)

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About You

44. In general, how would you rate your overall health?(*)

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45. In general, how would you rate your overall mental or emotional health?(*)

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46. What is your age?(*)

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47. Are you male or female?(*)

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48. What is the highest grade or level of school that you have completed?(*)

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49. Are you of Hispanic or Latino origin or descent?(*)

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50. What is your race? Mark one or more.(*)

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51. Did someone help you complete this survey?(*)

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52. How did that person help you? Mark one or more.(*)

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What other way?(*)
Please tell us what other way that person helped you.

Thank you for taking the time to complete our patient survey!


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