Clinic User Survey Clinic User Survey- Chiro

2005 Clinic User Survey

Chiropractic Sites

Draft Mail Questionnaire

SURVEY INSTRUCTIONS

• Answer all the questions by checking the box to the left of your answer.

• You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

 Yes If Yes, Go to Q.1 on Page 2

 No

All information that would let someone identify you or your family will be kept private. We will not share your personal information with anyone without your OK. You may choose to answer this survey or not. REVIEW WORDING WITH HRSA.

If you want to know more about this study, please call XXX-XXXX.

YOUR HEALTH CARE EXPERIENCES AT THIS CLINIC IN THE LAST 6 MONTHS

Q.1. In the last 6 months, did you visit this clinic during regular office hours to get help or advice for yourself?

use an x to mark your answer

1  Yes Go to Q.2

0  No END SURVEY; THE SURVEY IS ONLY FOR PEOPLE WHO HAVE VISITED THE CLINIC IN THE LAST 6 MONTHS.

Q.2. (If Yes) In the last 6 months, when you visited this clinic during regular office hours, how often did you get the help or advice you needed?

1  Never

2  Sometimes

3  Usually

4  Always

Q3. A health provider could be a general doctor, a specialist doctor, a chiropractor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care.

In the last 6 months, did you try to make an appointment with a doctor or other health provider at this clinic?

1  Yes

0  No GO TO Q.5

Q4. (If Yes) In the last 6 months, how often did you get an appointment at this clinic as soon as you wanted?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q5. In the last 6 months, how often were you taken to the exam room within 15 minutes of your arrival at the clinic?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q.6 In the last 6 months, how many times did you go to this clinic to get care for yourself?

MARK (X) ONE ANSWER

1  1 time

2  2 times

3  3 times

4  4 times

5  5 to 9 times

6  10 times or more

Q.7. In the last 6 months, how often did doctors or other health providers at this clinic listen carefully to you?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q8. In the last 6 months, how often did doctors or other health providers at this clinic explain things in a way you could understand?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q9. In the last 6 months, how often did doctors or other health providers at this clinic spend enough time with you?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q10. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care at this clinic in the last 6 months?

MARK (X) ONE ANSWER

0  0 Worst health care possible

1  1

2  2

3  3

4  4

5  5

6  6

7  7

8  8

9  9

10  10 Best health care possible

NECK AND BACK PAIN

Q.11. The following questions are about pain you may have experienced in the past 6 months.

During the last 6 months, did you have neck pain or low back pain?

1  YES

0  NO GO TO Q. 17, PAGE 4

Q12. A health provider could be a general doctor, a specialist doctor, a chiropractor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care.

In the last 6 months, have you seen a health provider at this clinic for treatment of neck or low back pain?

1  YES

0  NO GO TO Q. 17, PAGE 4

A. What type of provider did you see?

 Chiropractor

 Physician

 Physical therapist

 Other (please describe)

 Unsure

Q13. In the last 6 months, how many times did you go to this clinic to get treatment for neck or low back pain?

MARK (X) ONE ANSWER

1  1 time

2  2 times

3  3 times

4  4 times

5  5 to 9 times

6  10 times or more

Q14. In the last 6 months, how often did you get an appointment at this clinic for treatment of neck or low back pain as soon as you wanted?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q15. In the last 6 months, has any health provider in this clinic suggested you do any of the following things at home to help reduce neck or low back pain:

MARK (X) YES OR NO FOR EACH ITEM

Yes No

↓ ↓

1. Diet or lose weight 1 ¨ 2 ¨

2. Walking or other

physical activity 1 ¨ 2 ¨

3. Exercises, such as stretching 1 ¨ 2 ¨

4. Activities to reduce stress 1 ¨ 2 ¨

5. Change the way you get in

or out of cars or chairs 1 ¨ 2 ¨

6. Change your sleep position

or the type of bed or pillow

you use 1 ¨ 2 ¨

7. Moist heat 1 ¨ 2 ¨

8. Ice therapy 1 ¨ 2 ¨

9. Braces 1 ¨ 2 ¨

10. A battery powered stimulator to

reduce pain

(sometimes called a TENS) 1 ¨ 2 ¨

11. Over the counter pain relievers,

such as aspirin, ibuprofen,

or Tylenol, 1 ¨ 2 ¨

12. Anything else – (Please write your

answer in the space below) 1 ¨ 2 ¨

Q16. We want to know your rating of how well this clinic has done in treating your neck or low back pain.

Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate your care for neck and low back pain from this clinic in the last 6 months?

MARK (X) ONE ANSWER

0  0 Worst health care possible

1  1

2  2

3  3

4  4

5  5

6  6

7  7

8  8

9  9

10  10 Best health care possible

Q17. In the last 6 months, how many times did you see a chiropractor. Include all places you have seen chiropractors, not just at this clinic. Count each time you saw a chiropractor if you saw the same one more than once.

MARK (X) ONE ANSWER

0  None IF NONE, GO TO Q. 19, PAGE 5

1  1 time

2  2 times

3  3 times

4  4 times

5  5 to 9 times

6  10 times or more

Q18. [If you saw a chiropractor] In the past 6 months, about how much did you pay with your own money for chiropractic care?

0  None

1  $1 to $25,

2  $26 to $50,

3  $51 to $100,

4  $101 to $200,

5  $201 to $500,

6  More than $500?

ABOUT YOU

Q19. What kind of health insurance or health care coverage do you have?

MARK (X) FOR THE TYPE OF HEALTH INSURANCE YOU HAVE. IF YOU HAVE NO HEALTH INSURANCE, CHECK “NO COVERAGE OF ANY TYPE”

1  Private health insurance through your employer or that you bought yourself

2  Medicare (the government program for people 65 and older and people with certain disabilities)

3  Medicaid (the government assistance program that pays for health care for people in need)

4  Military health care (TRICARE/VA/CHAMP-VA)

5  Indian health service

6  Some other kind of coverage

[please describe]

7  No coverage of any type

Q20. In general, how would you rate your overall health now?

MARK (X) ONE ANSWER

1  Excellent

2  Very good

3  Good

4  Fair

5  Poor

Q21. Walking About

MARK (X) NEXT TO THE STATEMENT THAT BEST DESCRIBES YOUR OWN HEALTH TODAY

1  I have no problems in walking about

2  I have some problems in walking about

3  I am confined to bed

Q22. Washing or Dressing

MARK (X) NEXT TO THE STATEMENT THAT BEST DESCRIBES YOUR OWN HEALTH TODAY

1  I have no problems with washing or dressing myself

2  I have some problems with washing or dressing myself

3  I am unable to wash or dress myself

Q23. Usual Activities ( such as work, study, housework, family, or leisure activities)

MARK (X) NEXT TO THE STATEMENT THAT BEST DESCRIBES YOUR OWN HEALTH TODAY

1  I have no problems with performing my usual

activities

2  I have some problems with performing my

usual activities

3  I am unable to perform my usual activities

Q24. Pain or Discomfort

MARK (X) NEXT TO THE STATEMENT THAT BEST DESCRIBES YOUR OWN HEALTH TODAY

1  I have no pain or discomfort

2  I have moderate pain or discomfort

3  I have extreme pain or discomfort

Q25. Anxiety/Depression

MARK (X) NEXT TO THE STATEMENT THAT BEST DESCRIBES YOUR OWN HEALTH TODAY

1  I am not anxious or depressed

2  I am moderately anxious or depressed

3  I am extremely anxious or depressed

Q26. What is your age now?

MARK (X) ONE ANSWER

1  18 to 24

2  25 to 34

3  35 to 44

4  45 to 54

5  55 to 64

6  65 to 74

7  75 or older

Q27. Are you male or female?

MARK (X) ONE ANSWER

1  Male

2  Female

Q28. What is the highest grade or level of school that you have completed?

MARK (X) ONE ANSWER

1  8th grade or less

2  Some high school, but did not graduate

3  High school graduate or GED

4  Some college or 2-year degree

5  4-year college graduate

6  More than 4-year college degree

Q29. Are you of Hispanic or Latino origin or descent?

MARK (X) ONE ANSWER

1  Yes, Hispanic or Latino

2  No, not Hispanic or Latino

Q30. What is your race?

PLEASE MARK (X) ONE OR MORE ANSWERS

1  White

2  Black or African-American

3  Asian

4  Native Hawaiian or other Pacific Islander

5  American Indian or Alaska Native

6  Other

Q31. What language do you mainly speak at home?

MARK (X) ONE ANSWER

1  English

2  Spanish

3  Some other language

(PLEASE DESCRIBE BELOW)

Q32. Did someone help you complete this survey?

MARK (x) one answer

1  Yes

0  No

MPR DOCUMENTATION PURPOSES ONLY:

/home/ec2-user/sec/disk/omb/icr/200701-0915-004/doc/1552001

(REV—5/9/05) 2/6/2021 8:24 AM

Jen revised for Richard Strouse

NHSC – 6126-072