Patient Survey
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pdf
Filesize: 41597
Patient Survey
For most questions below, you simply need to check the box or boxes that
best match your answers. Please answer every question.
Male
Female
2.
Your age:
________Years
3.
Compared to other people your age, would you say that your health is (Please check ONE only)
Excellent
Good
Fair
Poor
4.
How many times did you see the Nurse Practitioner from this practice for a health-related issue in the
past 12 months?
____________ times in the past 12 months
5.
Have you accompanied a family member or someone in your care to see the Nurse Practitioner in the
past 12 months?
Yes
No
6.
Who first suggested you see the Nurse Practitioner?
Please check ONE only
My doctor
I decided to see a Nurse Practitioner myself
The receptionist suggested I see the Nurse Practitioner
Someone else in this office/clinic suggested I see the Nurse Practitioner (e.g. other
health care professional, social worker, dietician)
My family or friends recommended I see the Nurse Practitioner
Other (specify) __________________________
1.
Your gender:
7.
How did it happen that you saw the Nurse Practitioner today?
Please check ONE
main reason
I wanted to see the Nurse Practitioner and made the appointment
The doctor asked me to make this appointment to see the Nurse Practitioner
Another health care provider suggested that I make this appointment to see the Nurse
Practitioner
The receptionist suggested I see the Nurse Practitioner
The doctor was not available
Other (specify) __________________________
8.
What was the main reason for your visit to the Nurse Practitioner today?
Reason for visit today
Please check ONE
main reason
General information about my health or to ask questions about my health
Diet and lifestyle counselling
Annual or general check up
Care for a minor illness such as a cold or sore throat
Monitor an ongoing condition such as diabetes or asthma
Arrange to see another health care provider such as a dietician or psychologist
Check or renew my prescription medication
Pregnancy care
Check-up for my baby
Specific test such as a Pap test or prostate test
Support or counselling
Accompany a relative (e.g. a parent or child)
Participate in a group activity
Other (specify) __________________________
9.
What do you like about seeing the Nurse Practitioner?
Please Check ALL
that apply
The Nurse Practitioner gives support and information about how to look after my health
condition or problem
The Nurse Practitioner spends time with me to answer my questions or address my
concerns
The quality of care the Nurse Practitioner provides is excellent
I am able to see the Nurse Practitioner quickly when I have a health problem
I do not have to travel as far as I did in the past to see a health professional when I
have a health problem
The Nurse Practitioner makes home visits or provides care in the home
The Nurse Practitioner is available after regular office hours (e.g. after 5pm or on
weekends)
The Nurse Practitioner helps me find out where to get help from other services in the
community
The Nurse Practitioner is easy to talk to
Other (specify) __________________________ __________________
10.
Is there anything that you do NOT like about seeing the Nurse Practitioner? Please check ONE box
There are things I do not like about seeing the nurse practitioner. Please go to Question 11.
I have no concerns or problems with seeing the nurse practitioner. Please go to Question 12.
11.
What do you NOT like about seeing the Nurse Practitioner?
Please check ALL
that apply
I am not clear about the Nurse Practitioner’s role
I am not clear about the Nurse Practitioner’s knowledge, education or training
I do not feel that I can choose to see my doctor rather than the Nurse Practitioner
I am concerned that my doctor will not be aware of everything about my health and
about my concerns
Other (specify) _________________________ _______________________________
12.
For each statement below, please check the box that best matches your level of satisfaction:
1
Very
Satisfied
2
Somewhat
Satisfied
3
Somewhat
dissatisfied
4
Very
Dissatisfied
Care or advice you receive from the Nurse
Practitioner
The amount of time the Nurse Practitioner spends
with you
The availability of the Nurse Practitioner
The waiting time to get an appointment to see the
Nurse Practitioner
The waiting time to get an appointment to see the
Doctor
How the professionals in this centre work together
to help with your health problems
The way the nurse practitioner speaks and listens
to you
Optional Questions
13.
What is the highest level of education that you have completed? (Please check ONE only)
Less
than
grade
9 Grade 9 to 13
Some trade, vocational or community college
Some university
Diploma or certificate: trade, vocational/community college
University degree
14.
What was your total household income before taxes for 2002? (Please check ONE only)
Less than $ 10,000
$10,000 to $ 19,999
$ 20,000 to $ 29,999
$ 30,000 to $ 39,999
$ 40,000 to $ 49,999
$ 50,000 to $ 59,999
$ 60,000 to $ 69,999
$ 70,000 to $ 79,999
$ 80,000 to $ 99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 and over
THANK YOU FOR COMPLETING THIS SURVEY. PLEASE RETURN IT TO THE PERSON WHO GAVE THIS SURVEY
TO YOU TODAY BEFORE YOU LEAVE OR SEND IT IN THE STAMPED ADDRESSED ENVELOPE THAT IS
ENCLOSED WITHIN ONE WEEK
