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YouthClinic  

 

Background Information

1. If someone other than the parent of the patient is completing this survey please click here:
2. Patients first visit here:	Yes No NA
3. Patients Sex:	Male Female NA
4. Patients Age:	0-3 4-8 9-12 13-18 NA
5. How many minutes did you wait after your scheduled appointment time before you were called to an exam room:	Right Away 1-5 minutes 6-10 Minutes 11-15 Minutes More than 15 Minutes NA
6. How many minutes did you wait in the exam room before you were seen by one of our providers:	Right Away 1-5 Minutes 6-10 Minutes 11-15 Minutes More than 15 Minutes NA
7. Patients Name (Optional):

Access To Care

Rate us using a scoring system of 1 to 5, with 1 being poor and 5 being excellent.

1.  Ease of scheduling your child's appointment:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
2. Courtesy of Person who scheduled your child' s appointment:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
3.  Our helpfulness on the telephone:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
4.  Promptness in returning your call:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
5.  Please indicate type of call you were waiting for:	Prescription Phone Nurse Business Office Provider Appointment Other NA
6. Comments on Access to Care:

During Your Visit

1. Speed of the registration process:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
2. Courtesy of Staff in the Registration Area:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
3. Comfort Of The Waiting Area:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
4. Comfort Of The Exam Room:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
5. Friendliness/Courtesy of Nurse/Assistant:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
6. Concern Shown for your Child's Problem:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
7. Please indicate What type Of Service You Accessed:	General Care Emergency Speech Psychology Well Care NA
8. Comments (Please Describe Good Or Bad Experiences)

Your Care Provider

1. Rate your experience in terms of access for Well-Care Visits to your Preferred Care provider:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
2. Friendliness/Courtesy Of Care Provider:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
3. Rate The Explanations your Care Provider gave you about your childs problem or condition:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
4. Concern Care Provider showed for you and your Child's questions or worries:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
5. Care Providers efforts to include you in decisions regarding your child's treatment:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
6. Information your Care provider gave you about medications:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
7. Instructions your Care Provider gave you about Follow-up Care:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
8. Degree to which Care Provider talked with you and your child using words you and your child understand:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
9. Amount Of time Care provider spent with you and your child:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
10. Your Confidence in this Care Provider:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
11. Likelihood of recommending Care provider to others:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
12. Which Provider Did you see:	McGinnis Elliott Guenther Sullivan Hanson Brockway O'Leary Ballard Beno Ramsey Beard Kehmeier Lein Baker Hess Scanga Riffe Batezel Mesinger NA
13. Comments:

Phone Nurse

1. Friendliness/Courtesy of the phone nurse:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
2. Was the Phone Nurse helpful and Informative:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
3. Did you feel confident in the advice given:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
4. Comments:

 Personal Issues

1. Convenience Of Office Hours:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
2. Our concern for your Privacy:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
3. Our Sensitivity to Your Needs:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
4. Ease of Finding our Office:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
5. Convenience Of parking:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
6. Courteous and Timely Assistance from  our After Hours Answering Service:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
7. Courteous and Timely Assistance from After Hours Nursing Service:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
8. Comments:

Business Issues

1. Professionalism of Business Office in handling your inquiries:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
2. Were your Billing and Insurance questions answered to your satisfaction:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
3. Did the Business Office staff respond to your calls in a timely manner:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
4. Are statements concise and easy to understand:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
5. Were needed referrals supplied to you in a timely fashion:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
6. Comments

Medical Records

1. Were you given appropriate access to your medical records:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
2. Were records supplied to you in a timely fashion:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
3. Do you feel that your health information is properly protected:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
4. Comments:

General Information

1. How long have you been a patient with Fort Collins Youth Clinic:	0-1 Year 1-5 Years 6-10 Years 10 + Years NA
2. How many Children do you have in our practice:	1 2 3 4 5 6+ NA
3. Have you Recommended the Fort Collins Youth Clinic to other parents:	Yes No NA
4. Did you know that we have a website:	Yes No NA
5. What information have you accessed from our website:	Hours Directions Patient Survey Newsletters Medical Forms Privacy Forms Provider Info Dosage Guidelines Medical Tips NA
6. What is the best thing about the Youth Clinic:
7. What frustrates You about our clinic:
8. At which office was your child seen:	North South Windsor NA
9. What Was the Date and Time Of your Appointment:

Electronic Medical Record

1. Do you feel that our Electronic Medical Record has improved the quality of your child's visit to the Youth Clinic:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
2. Do you feel that our Electronic Medical Record has improved your interaction with the Provider:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
3. Do you feel that our Electronic Medical Record has improved your interaction with the nurse:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
4. Does it seem that the Providers have more clinical information available to them because of the Electronic Medical Record:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
5. When seeking medical care for sick or urgent needs for your child, do you always come to the Youth Clinic:	0 - Poor 1 - Below Average 2 - Average 3 - Slightly Above Average 4 - Great 5 - Excelllent NA
6. If not Why?

 

 

 

 

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