Health Assessments in Primary Care: A How-to Guide

Appendix 11: Patient Feedback Survey Example

Note: Revise this survey as needed to fit with your practice and patient population.

We have started using a new health assessment questionnaire to improve our care. We want to hear from you about how the health assessment process is working in our practice so we can continue to improve our care to you. Please answer a few questions about the health assessment that you completed. Please return this completed survey to the front desk before you leave. Your answers to the questions are confidential.

For the following questions about the health assessment you completed, please indicate how well each statement applies to your experience.

1. The questions on the assessment were easy to answer.___ Yes
___ Somewhat
___ No
2. I had enough time to complete the assessment.___ Yes
___ Somewhat
___ No
3. I know why I completed the assessment.___ Yes
___ Somewhat
___ No
4. My provider let me know that he or she had reviewed my assessment.___ Yes
___ Somewhat
___ No
5. I talked with my provider about my answers to questions on the assessment.___ Yes
___ Somewhat
___ No
6. The assessment covered most of my current health concerns.___ Yes
___ Somewhat
___ No
7. Overall, I think that completing the assessment will help my doctor provide better care.___ Yes
___ Somewhat
___ No

 

Please help us make the health assessment better by answering a few more questions:

8. What other health topics or concerns should the assessment ask about that are important to you?

_________________________________________________________________________

 

9. How can the information on the assessment be made more useful to you to improve your health ?

_________________________________________________________________________

 

10. How else can we make the health assessment process better?

_________________________________________________________________________

 

Thank you!   

Current as of September 2013
Internet Citation: Health Assessments in Primary Care: A How-to Guide: Appendix 11: Patient Feedback Survey Example. September 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/health-assessments/health-assessment-ap11.html