Western NC Community Health Services Patient Satisfaction Survey
Please take a few minutes to complete this survey. We want to know how you feel about the care you received today at our health center. Your feedback is important to us.
Provider seen today? (or at last visit) *
What is the age of the person receiving care?
Clear selection
What is your gender?
Clear selection
Do you consider yourself Hispanic or Latino?
Clear selection
What is your race?
Clear selection
Access to Care
Very Good
Good
Fair
Poor
Able to get appointment for checkups, yearly exams, well-visits, regular follow up visits
Health center hours work for me
Phone calls get through easily
Able to get medical advice when the office is closed
Length of waiting time at the clinic
Able to make same day appointments when sick or hurt
I get called back quickly
Staff was friendly, respectful, and helpful to you
Time spent in check out
Clear selection
Facility
Very Good
Good
Fair
Poor
Lobby and waiting room were comfortable
Exam room was clean and comfortable
The clinic was handicap accessible (Leave blank if this does not apply)
Easy to find the clinic
Clear selection
Nurses & Medical Assistants
Very Good
Good
Fair
Poor
Listened to you
Friendly respectful, and helpful to you
Answered your questions in a way you could understand
Clear selection
Healthcare Provider - the person who took care of you today.
Very Good
Good
Fair
Poor
Listened to you?
Spent enough time with you?
Answered your questions in a way you could understand?
Was friendly and helpful to you?
Gave you information you could understand?
Considered your personal and family beliefs?
Involves other doctors and caregivers in your care when needed?
Gives you good advice and treatment?
Clear selection
Healthcare Provider - Medicine
Yes
No
Don't Know
Were you asked if you have problems with the medicine you take?
Did you have problems getting your medicine? (transportation, pharmacy hours, or cost)
Clear selection
General Information
Yes
No
Don't Know
Have you ever been given information on what it means to have a "medical home"?
Do you feel we are your medical home?
Do you see the same provider for most of your visits to our clinic?
Were you asked today if you had visits with other healthcare providers since your last visit with us?
If you may need other services that we don't provide, did we help you find the care you needed?
Were you helped with making appointments to see other providers or for specialty care? (Leave blank if this does not apply)
Would you send your family and friends to us?
Did someone talk with you about your health goals today?
Do you feel what you pay is reasonable?
Do you understand what we ask you to pay for your care?
Have you applied for our WNC Care sliding fee discount program?
Have you ever missed an appointment at our clinic because you did not have the money to pay?
Clear selection
What one thing could we do to make your visits better? Please share any other comments or feedback.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy