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We would like your honest feedback. Please answer these questions either yes or no about the visit you had today. Think about a specific provider or staff member—for example, your doctor, nurse, medical assistant—when answering.
1. Did this clinician or staff member explain things in a way that was easy to understand? | Yes | No |
2. Did this clinician or staff member use medical words you did not understand? | Yes | No |
3. Was this clinician or staff member warm and friendly? | Yes | No |
4. Did this clinician or staff member listen carefully to you? | Yes | No |
5. Did this clinician or staff member encourage you to ask questions? | Yes | No |
6. Did this clinician or staff member answer all your questions to your satisfaction? | Yes | No |
7. Did you see this clinician or staff member for a specific illness or for any health condition? | Yes | No |
If No, Form Is Complete | ||
a. Did this clinician or staff member give you instructions about what to do to take care of this illness or health condition? | Yes | No |
If No, Form Is Complete | ||
b. Were these instructions easy to understand? | Yes | No |
c. Did this clinician or staff member ask you to describe how you were going to follow these instructions? | Yes | No |