PatCentrdMedHome_Long form

OMB Number 2900-0712
Est. Burden: 20 minutes
VA Form 10-1465-5

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
AMBULATORY CARE 2013
In order for the VA to carry out its mission to provide the best possible medical care and
services to all veterans, it is extremely important that you complete and return this survey
booklet. Your answers will help ensure that all veterans receive the high-quality care they
have earned and so richly deserve.
Please read each question and check the box that best describes your experience. Please be
sure to read all pages of this survey booklet.
We want to remind you that all information is strictly anonymous. It will not be shared with
your doctor or affect your VA care.
Your Privacy is Protected. All information that would let someone identify you or your family will be
kept private. Synovate will not share your personal information with anyone without your OK. Your
responses to this survey are also completely confidential.
Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to,
this will not affect the health care you get.
If you have a specific question or need help with your VA care, you may contact the VA as
described at the end of this survey booklet.
Thank you very much!
The Paperwork Reduction Act of 1995: This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you
are not required to respond to, a collection of information unless it displays a valid OMB number. We
anticipate that the time expended by all individuals who complete this survey will average 10 minutes.
This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
Customer satisfaction surveys are used to gauge customer perceptions of VA services as well as
customer expectations and desires. The results of this survey will lead to improvements in the quality
of service delivery by helping to shape the direction and focus of specific programs and services.
Disclosure of information involves release of statistical data and other non-identifying data for the
improvement of services within the VA healthcare system and associated administrative purposes.
Submission of this form is voluntary and failure to respond will have no impact on benefits to which
you may be entitled.

Version: 43 – 0713

SURVEY INSTRUCTIONS


Answer each question by marking 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 #1
No

YOUR PROVIDER
1.

Our records show that you got care
from the provider named below in the
last 12 months.
[CLINICIAN NAME]
Is that right?




YOUR CARE FROM THIS PROVIDER IN
THE LAST 12 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.
4.

Yes
NoIf No, go to #44









The questions in this survey will refer to the
provider named in Question 1 as “this
provider.” Please think of that person as
you answer the survey.
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?



3.

No

How long have you been going to this
provider?






2

Yes

Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more

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

5.

None If None, go to #44
1 time
2
3
4
5 to 9
10 or more times

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?




Yes
NoIf No, go to #8

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?





7.

9.

Usually
Always

Same day
1 day
2 to 3 days
4 to 7 days
More than 7 days

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




Yes
No If No, go to #10

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?









Yes
No

Sometimes

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






8.

Never

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

Never
Sometimes
Usually
Always

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




Yes
No If No, go to #13

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?






Never
Sometimes
Usually
Always

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




Yes
No If No, go to #15

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?






Never
Sometimes
Usually
Always

3

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




Yes
No If No, go to #17

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?






Never
Sometimes
Usually
Always

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?




Yes
No

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?






4

Never
Sometimes
Usually
Always

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






Never
Sometimes
Usually
Always

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






Never
Sometimes
Usually
Always

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




Yes
No If No, go to #23

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






Never
Sometimes
Usually
Always

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






Never
Sometimes
Usually
Always

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






Never
Sometimes
Usually
Always

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






Never
Sometimes
Usually
Always

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




Yes
No If No, go to #28

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?






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




Yes
No If No, go to #32

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?






Not at all
A little
Some
A lot

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?






Not at all
A little
Some
A lot

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




Yes
No

Never
Sometimes
Usually
Always
5

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?













0

Worst provider possible

1
2
3
4
5
6
7
8
9
10 Best provider possible

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?




Yes
No If No, go to #35

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?






6

Never
Sometimes
Usually
Always

Please answer these questions about the
provider named in Question 1 of the survey.
35. In the last 12 months, did anyone in this
provider’s office talk with you about
specific goals for your health?




Yes
No

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?




Yes
No

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




Yes
No If No, go to #39

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?




Yes
No

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?




Yes
No

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?




Yes
No

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?




Yes
No

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?






Never
Sometimes
Usually
Always

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






Never
Sometimes
Usually
Always

ABOUT YOU
44. In general, how would you rate your
overall health?







Excellent
Very Good
Good
Fair
Poor

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







Excellent
Very Good
Good
Fair
Poor

46. Do you now smoke cigarettes or use
tobacco every day, some days, or not at
all?






Every day
Some days
Not at all  If Not at all, go to #50
Don’t know  If Don’t know, go to #50

47. In the last 12 months, how often were
you advised to quit smoking or using
tobacco by a VA doctor or other VA
health provider?






Never
Sometimes
Usually
Always

7

48. In the last 12 months, how often was
medication recommended or discussed
by a VA doctor or VA health provider to
assist you with quitting smoking or
using tobacco? Examples of
medication are: nicotine gum, patch,
nasal spray, inhaler, or prescription
medication.






Never
Sometimes
Usually
Always

49. In the last 12 months, how often did
your VA doctor or VA health provider
discuss or provide methods and
strategies other than medication to
assist you with quitting smoking or
using tobacco? Examples of methods
and strategies are: telephone helpline,
individual or group counseling, or
cessation program.






Never
Sometimes
Usually
Always

50. Do you take aspirin daily or every other
day?





Yes
No
Don’t know

51. Do you have a health problem or take
medication that makes taking aspirin
unsafe for you?





8

Yes
No
Don’t know

52. Has a VA doctor or VA health provider
ever discussed with you the risks and
benefits of aspirin to prevent heart
attack or stroke?




Yes
No

53. Are you aware that you have any of the
following conditions? Check all that
apply.





High cholesterol
High blood pressure
Parent or sibling with heart attack
before the age of 60

54. Has a VA doctor ever told you that you
have any of the following conditions?
Check all that apply.






A heart attack
Angina or coronary heart disease
A stroke
Any kind of diabetes or high blood
sugar

55. How often did you have a drink
containing alcohol in the past 12
months? Consider a "drink" to be a can
or bottle of beer, a glass of wine, a wine
cooler, or one cocktail or a shot of hard
liquor (like scotch, gin or vodka).
Please mark only one.








Never  If Never, go to #59
Monthly or less
2-4 times a month
2-3 times a week
4-5 times a week
6 or more times a week

56. How many drinks containing alcohol did
you have on a typical day when you
were drinking in the past 12 months?








0 drinks (Did not drink in the past 12
months)  If 0, go to #59
1-2 drinks
3-4 drinks
5-6 drinks
7-9 drinks
10 or more drinks

57. How often did you have 6 or more
drinks on one occasion in the past 12
months?







Never

a. Moderate activities, such as moving a
table, pushing a vacuum cleaner,
bowling, or playing golf?





Yes, limited a lot
Yes, limited a little
No, not limited at all

b. Climbing several flights of stairs?





Yes, limited a lot
Yes, limited a little
No, not limited at all

Less than monthly
Monthly
Weekly
Daily or almost daily

58. In the past 12 months has a VA doctor
or other VA health care provider
advised you about your drinking (to
drink less or not to drink alcohol)?




59. The following two questions are about
activities you might do during a typical
day. Does your health now limit you in
these activities? If so, how much?

Yes
No

60. During the past 4 weeks, have you had
any of the following problems with your
work or other regular daily activities as
a result of your physical health?
a. Accomplished less than you would like?







No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time

b. Were limited in the kind of work or
other activities?







No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time

9

61. During the past 4 weeks, have you had
any of the following problems with your
work or other regular daily activities as
a result of any emotional problems
(such as feeling depressed or anxious)?

62. During the past 4 weeks, how much did
pain interfere with your normal work
(including both work outside the home
and housework)?







a. Accomplished less than you would
like







No, none of the time
Yes, a little of the time

Not at all
A little bit
Moderately
Quite a bit
Extremely

Yes, some of the time
Yes, most of the time
Yes, all of the time

b. Didn't do work or other activities as
carefully as usual







No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time

63. How much of the time during the past 4 weeks:

a.

Have you felt calm and
peaceful?

b. Did you have a lot of
energy?
c.

10

Have you felt
downhearted and blue?

All of
the time

Most of
the time

A good
bit of the
time





































Some of
the time

A little of
the time

None of
the time

64. How much of the time during the
past 4 weeks has your physical
health or emotional problems
interfered with your social
activities (like visiting with friends,
relatives, etc.)?







All of the time
Most of the time
Some of the time
A little of the time
None of the time

65. Have you been treated by a VA
provider for chronic pain in the
past 12 months?




Yes
No

66. If you have been treated by a VA
provider for chronic pain, please
rate the effectiveness of your pain
treatment?







Poor

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









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




8th grade or less






High school graduate or GED

Some high school, but did not
graduate
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

White
Black or African-American
Asian
Native Hawaiian or other Pacific
Islander
American Indian or Alaska Native

70. What language do you mainly
speak at home?








Good
Excellent

No, Not Hispanic or Latino

69. What is your race? Mark one or more.

Fair
Very good

Yes, Hispanic or Latino

English
Spanish
Chinese
Russian
Vietnamese
Some other language (please
print):
__________________________

71. Did someone help you complete
this survey?




Yes
No  Thank you. Please return
the completed survey in
the postage-paid envelope.

72. How did that person help you?
Mark one or more.






Read the questions to me



Helped in some other way

Wrote down the answers I gave
Answered the questions for me
Translated the questions into
my language

11

THANK YOU
Please return the completed survey in the postage-paid envelope.

If you have a specific question or need help with your VA care, you may contact the VA:
1. By telephone:
a. VA Benefits: 1-800-827-1000
b. Health Care Benefits: 1-877-222-8387
c. Telecommunications Device for the Deaf (TDD): 1-800-829-4833
2. Information on a broad range of veterans' benefits is available on our home page at
http://www.va.gov
3. At your local VA medical center, either contact the department that you think can help
you or ask for the Patient Advocate.

Your answers are important to help us improve VA care. Thank you for completing this
questionnaire. Please place the completed questionnaire in the envelope we sent you.
No stamp is required. Simply place the envelope in any mailbox and return the survey to:
Department of Veterans Affairs
c/o Synovate
P.O. Box 806046
Chicago, IL 60680