0917-0036 Patient Wellness Survey

Patient Wellness Survey

1. Introduction
The Wind River Service Unit (WRSU) is committed to improving the quality of patient care by being 
accredited as a Primary Care Medical Home (PCMH). PCMH means working with the bigger health 
care community to meet your medical needs. This patient care survey is one way to improve services. 
It allows us to see the bigger picture to your health service needs. Patient care begins with you. 
Please complete the survey based upon your last or immediate visit. It takes about 5 minutes to finish. 
Thank you for helping improve patient care. 

Form Approved 
OMB Form No. 0917­0036 
Expiration Date: 5/31/2015 
1. What is your age (by years)?
j 18­25
k
l
m
n

j 26­33
k
l
m
n

j 34­41
k
l
m
n

j 42­49
k
l
m
n

j 50­57
k
l
m
n

j 58­65
k
l
m
n

j Over 66
k
l
m
n

2. What is your gender?

j Female
k
l
m
n

j Male
k
l
m
n

3. Rate your satisfaction with the change of hours to "8:00 a.m. to 5:30 p.m. (available at
noon hour), Monday­Friday, at WRSU."

j 1­Very 
k
l
m
n

j 2­Unsatisfied
k
l
m
n

j 3­Neutral
k
l
m
n

j 4­Satisfied
k
l
m
n

j 5­Very Satisfied
k
l
m
n

Unsatisfied 

4. I receive my health care services from (check all that apply):

j Fort Washakie Health Center
k
l
m
n

j Arapahoe Health Center
k
l
m
n

j Care mostly outside IHS
k
l
m
n

5. Today, I am completing this patient care survey form:

j at Fort Washakie Health Center
k
l
m
n

j online
k
l
m
n

j at Arapahoe Health Center
k
l
m
n

j by mail
k
l
m
n

j by telephone
k
l
m
n

6. What services are you receiving today?
c Behavioral Health
d
e
f
g

c Lab/X­Ray
d
e
f
g

c Clinic Health Care
d
e
f
g

c Optometry
d
e
f
g

c Community Health/Public Health Nursing
d
e
f
g

c Contract Health Services (CHS)
d
e
f
g

c Dental
d
e
f
g

c Pharmacy
d
e
f
g

c Physical Therapy
d
e
f
g

c Other (please list here):
d
e
f
g

Page 1

Patient Wellness Survey
Note for question #13, page 2: Principles mean regular health maintenance checks, e.g., immunizations, pap smears. 
Life style changes are healthy practices examples are eating healthy, proper sleep and exercise. 

2. Patient Wellness
Patient wellness can be difficult when you are ill or have an ongoing (chronic) condition. Please share 
your recent health care visit whether with your primary care provider (PCP), the nurse, or anyone who 
treated your illness and/or provided direct care services. 
7. The provider and/or care team listens carefully to me or my personal caregiver.

j 1­Never
k
l
m
n

j 2­Rarely
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l
m
n

j 3­Sometimes
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l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

8. My provider and/or health care team gave easy to understand instructions about taking
care of my health concerns.
j Strongly 
k
l
m
n

j Disagree
k
l
m
n

j Neutral (neither 
k
l
m
n

Disagree 

j Agree
k
l
m
n

j Strongly Agree
k
l
m
n

agree or disagree) 

9. The provider and/or care team knows important facts about my health history.

j 1­Never
k
l
m
n

j 2­Rarely
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l
m
n

j 3­Sometimes
k
l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

10. The provider and/or care team did a health risk appraisal and assessment that was
discussed with me.

j 1­Never
k
l
m
n

j 2­Rarely
k
l
m
n

j 3­Sometimes
k
l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

11. The amount of time spent with the provider is just right.
j Strongly 
k
l
m
n

j Disagree
k
l
m
n

j Neutral (neither 
k
l
m
n

Disagree 

j Agree
k
l
m
n

j Strongly Agree
k
l
m
n

agree or disagree) 

12. The provider and/or care team is thorough and responds to my patient needs.
j 1­Strongly 
k
l
m
n

j 2­Disagree
k
l
m
n

Disagree 

j 3­Neutral 
k
l
m
n

j 4­Agree
k
l
m
n

j 5­Strongly Agree
k
l
m
n

(neither agree or 
disagree) 

13. My provider and/or care team talked to me about specific principles and/or making
lifestyle changes to help me prevent illness.

j 1­Never
k
l
m
n

j 2­Rarely
k
l
m
n

j 3­Sometimes
k
l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

14. The provider and/or care team asks about my concerns, worries and/or stressors.

j 1­Never
k
l
m
n

j 2­Rarely
k
l
m
n

j 3­Sometimes
k
l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

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Patient Wellness Survey
15. The provider and/or care team asks about my mental health status (example, sad,
empty or depressed.)

j 1­Never
k
l
m
n

j 2­Rarely
k
l
m
n

j 3­Sometimes
k
l
m
n

j 4­Often
k
l
m
n

j 5­Always
k
l
m
n

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

j Poor
k
l
m
n

j Fair
k
l
m
n

j Good
k
l
m
n

j Excellent
k
l
m
n

17. I can manage and control most of my health problems.

j Strongly 
k
l
m
n

j Disagree
k
l
m
n

j Neutral (neither 
k
l
m
n

Disagree 

j Agree
k
l
m
n

j Strongly Agree
k
l
m
n

agree or disagree) 

18. How do you manage your own health care?

19. My thoughts and beliefs can help or hurt my health condition.

j Strongly Disagree
k
l
m
n

j Disagree
k
l
m
n

j Neutral (neither agree 
k
l
m
n

j Agree
k
l
m
n

or diagree) 

20. I am comfortable talking to my Primary Care Provider and other clinic staff about my
health condition(s).

j Strongly Disagree
k
l
m
n

j Disagree
k
l
m
n

j Neutral (neither agree 
k
l
m
n

j Agree
k
l
m
n

or diagree) 

21. My provider and/or care team talked to me about transition of care to outside providers
and/or facilities.

j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n

j Often
k
l
m
n

j Always
k
l
m
n

j Not 
k
l
m
n

applicable 

22. My provider and/or care team talk to me about end­of­life care.

j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n

j Often
k
l
m
n

j Always
k
l
m
n

j Not 
k
l
m
n

applicable 

23. There are health education and self­help resources available at the clinic(s).

j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n

j Often
k
l
m
n

j Always
k
l
m
n

24. I was provided with non­IHS referrals to address my health concerns

j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n

j Often
k
l
m
n

j Always
k
l
m
n

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Patient Wellness Survey
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information 
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917­
0036. The time required to complete this information collection is estimated to average 5 minutes per response, 
including the time to review instructions, search existing data resources, gather data needed, and complete and review 
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for 
improving this form, please write to U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence 
Ave., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer. 

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