LFPC Survey
CAHPS Clinical & Group Survey (PCMH 3.0) Adult
Survey Instructions
Answer each question by marking the box to the left of your answer.

Your Privacy is Protected. All information that would let someone identify you or your family will be kept private. Litchfield Family Practice Center will not share your personal information with anyone without your OK. Your responses to this survey are also completely confidential.

Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to, this will not affect the health care you get from Litchfield Family Practice Center.

You are sometimes told to skip over some questions in this survey.
When this happens you will see an arrow with a note that tells you what question to answer next.
Your Provider
1. Choose the provider that you received care from in the last 6 months. If you have not had an appointment with a provider listed below please go to question #23.
2. Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?
3. How long have you been going to this provider?
Your care from this provider in the last 6 months
These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.
4. In the last 6 months, how many times did you visit this provider to get care for yourself?
5. 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?
6. 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?
7. In the last 6 months, did you make any appointments for a check-up or routine care with this provider?
8. In the last 6 months, when you made an appointment for a check-up or routine care with his provider, how often did you get an appointment as soon as you needed?
9. In the last 6 months, did you contact this provider’s office with a medical question during regular office hours?
10. 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?
11. In the last 6 months, how often did this provider explain things in a way that was easy to understand?
12. In the last 6 months, how often did this provider listen carefully to you?
13. In the last 6 months, how often did this provider seem to know the important information about your medical history?
14. In the past 6 months, how often did this provider show respect for what you had to say?
15. In the last 6 months, how often did this provider spend enough time with you?
16. In the last 6 months, did this provider order a blood test, x-ray, or other test for you?
17. 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?
18. 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?
19. In the last 6 months, did you take any prescription medicine?
20. 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?
Clerks and Receptionists at the Providers Office
21. In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be?
22. In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect?
About You
23. In general, how would you rate your overall health?
24. In general, how would you rate your overall mental or emotional health?
25. What is your age?
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