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Osteopathic Family Medicine, LLC
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Alcohol Questionnaire
Change of contact or insurance information
Depression Screening Questionaire (PHQ-9)
Eating Disorder Screening
GAD-7
Medicare Health Risk Assessment
Patient Satisfaction Survey - CAHPS/PCMH Version 3.0
Social Determinants of Health
Patient Satisfaction Survey - CAHPS/PCMH Version 3.0
Which provider did you most recently see?
Aaron Way, D.O.
Jamie Oakley, PA-C
Jill Berk, APRN, FNP-C
Melissa Roch, APRN, FNP-C
Our records show that you got care from the provider named below in the last 6 months. Is that right?
YES
NO
Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?
YES
NO
How long have you been going to this provider?
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 6 months, how many times did you visit this provider to get care for yourself?
1
2
3
4
5
6
7
8
9
10
In the last 6 months, did you contact this provider's office to get an appointment for an illness, injury, or condition that needed care right away?
YES
NO (Skip next question)
In the last 6 months, when you contacted 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?
Never
Sometimes
Usually
Always
In the last 6 months, did you make any appointments for a check-up or routine care with this provider?
YES
NO (Skip next question)
In the last 6 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?
Never
Sometimes
Usually
Always
In the last 6 months, did you contact this provider's office with a medical question during regular office hours?
YES
NO (Skip next question)
In the last 6 months, when you contacted 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
In the last 6 months, how often did this provider explain things in a way that was easy to understand?
Never
Sometimes
Usually
Always
In the last 6 months, how often did this provider listen carefully to you?
Never
Sometimes
Usually
Always
In the last 6 months, how often did this provider seem to know the important information about your medical history?
Never
Sometimes
Usually
Always
In the last 6 months, how often did this provider show respect for what you had to say?
Never
Sometimes
Usually
Always
In the last 6 months, how often did this provider spend enough time with you?
Never
Sometimes
Usually
Always
In the last 6 months, did this provider order a blood test, xray, or other test for you?
YES
NO (Skip next question)
In the last 6 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?
Never
Sometimes
Usually
Always
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
1
2
3
4
5
6
7
8
9
10
In the last 6 months, did you take any prescription medicine?
YES
NO (Skip next question)
In the last 6 months, how often did you and someone from this provider's office talk about all the prescription medicines you were taking?
Never
Sometimes
Usually
Always
In the last 6 months, how often were clerks and receptionists at this provider's office as helpful as you thought they should be?
Never
Sometimes
Usually
Always
In the last 6 months, how often did clerks and receptionists at this provider's office treat you with courtesy and respect?
Never
Sometimes
Usually
Always
In general, how would you rate your overall health?
Excellent
Very Good
Good
Fair
Poor
In general, how would you rate your overall mental or emotional health?
Excellent
Very Good
Good
Fair
Poor
What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
Are you male or female?
MALE
FEMALE
What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, Not Hispanic or Latino
What is your race? Mark one or more.
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other
Did someone help you complete this survey?
YES
NO --> THANK YOU
How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
* Required field
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