This 12-Month Survey is ONLY for patients that have seen their provider within the last 12 months.
Answer each question by checking the radio button next to your answer.
All fields marked with an (*) are required.
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
This survey will take approximately 8-12 minutes to complete.
Please come back and take this survey when you can easily spend 8-12 minutes answering questions without any interruptions. Thank you!
5 to 9 times
10 or more times
2 to 3 days
4 to 7 days
More than 7 days
Not At All
0 Worst provider possible
10 Best provider possible
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
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
Yes, Hispanic or Latino
No, not Hispanic or Latino
Black or African American
Native Hawaiian or Other Pacific Islander
American Indian or Alaskan Native
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
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