Form OMB No. 0917-0036- OMB No. 0917-0036- OMB No. 0917-0036-24, IPC Patient Experience Survey

Patient Experience Survey

1. I have a person who I think of as my personal doctor or nurse.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

2. It is very easy for me to get medical care when I need it.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

3. Most of the time, when I visit my doctor’s office, it is well organized and does not waste my time.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

4. The information given to me about my health problems is very good.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

5. I am sure that I can manage and control most of my health problems.

1 I do not have any 2 Not very sure 3 Somewhat sure 4 Very sure

health problems

6. Overall, the care I receive at ___________________ (add your clinic name) meets my needs.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

7. I receive exactly the care I want and need exactly when and how I want and need it.

1 Strongly Disagree 2 Disagree 3 Neither Disagree or Agree 4 Agree 5 Strongly Agree

Comments:

Revised 11/15/11