Your Provider 4. In the last 6 months, how many times did Our records show that you got care from 1. you visit this provider to get care for the provider named below in the last 6 yourself? months. None If None, go to #23 on page 4 Bassam G. Rizk MD 1 time Fawzi S. Farha MD 2 3 Is that right? 4 1 Yes 5 to 9 2 No If No, go to #23 on page 4 10 or more times The questions in this survey will refer to the In the last 6 months, did you contact this 5. provider named in Question 1 as “this provider.” to get an appointment for provider’s office Please think of that person as you answer the an illness, injury, or condition that needed survey. care right away? 1 Yes 2. Is this the provider you usually see if you 2 No If No, go to #7 need a check-up, want advice about a health problem, or get sick or hurt? 6. In the last 6 months, when you contacted 1 Yes this to get an appointment provider’s office 2 No for care you needed right away, how often did you get an appointment as soon as you needed? 3. How long have you been going to this provider? 1 Never 1 Less than 6 months 2 Sometimes 2 At least 6 months but less than 1 year 3 Usually 3 At least 1 year but less than 3 years 4 Always 4 At least 3 years but less than 5 years 5 5 years or more In the last 6 months, did you make any 7. appointments for a check-up or routine with this provider? care 1 Yes Your Care From This Provider in the 2 No If No, go to #9 Last 6 Months These questions ask about your own health care. Do include care you got when you not stayed overnight in a hospital. Do not include the times you went for dental care visits.
Your Provider 1. Our records show that you got care from the provider named below in the last 6 months. Bassam G. Rizk MD Fawzi S. Farha MD Is that right? 1 Yes 2 No If No, go to #23 on page 4 The questions in this survey will refer to the provider named in Question 1 as “this provider.” Please think of that person as you answer the survey. 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? 1 Yes 2 No 3. How long have you been going to this provider? 1 Less than 6 months 2 At least 6 months but less than 1 year 3 At least 1 year but less than 3 years 4 At least 3 years but less than 5 years 5 5 years or more 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? None If None, go to #23 on page 4 1 time 2 3 4 5 to 9 10 or more times 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? 1 Yes 2 No If No, go to #7 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? 1 Never 2 Sometimes 3 Usually 4 Always 7. In the last 6 months, did you make any appointments for a check-up or routine care with this provider? 1 Yes 2 No If No, go to #9
First-Coast-Surgery-FRONT-DESK-SURVEY.docx