This Survey is an anonymous survey and when you complete and send it, SDUIH does not know your email address or who completed the survey.

We appreciate you taking the time to share Your Viewpoint with us about our practice.

Select the Clinic site you visited:			please select Pierre Aberdeen Sioux Falls
Please rate the following questions about the visit you just made to this office
Question	Excellent	Very Good	Good	Fair	Poor
1. The amount of time you waited to get an appointment.
2. Convenience of the location of the office.
3. Getting through to the office by phone.
4. Length of time waiting at the office.
5. Time spent with the person you saw.
6. Explanation of what was done for you.
7. The technical skills (thoroughness, carefulness, competence) of the person you saw.
8. The personal manner (courtesy, respect, sensitivity, friendliness) of the person you saw.
9. The Clinician’s sensitivity to your special needs or concerns.
10. Your satisfaction with getting the help that you needed.
11. Your feeling about the overall quality of the visit.
General Questions: Please answer the general questions about your satisfaction with this practice.
12. If you could go anywhere to get health care, would you choose this practice or would you prefer to go someplace else?			please select Would choose this practice Might prefer someplace else Not sure
13. I am delighted with everything about this practice because my expectations for service and quality of care are exceeded.			please select Agree Disagree Not sure
14. In the last 12 months, how many times have you gone to the emergency room for your care?			please select None One time Two times Three or more times
15. In the last 12 months was it always easy to get a referral to a specialist when you felt like you needed one?			please select Yes No Does not apply to me
16. In the last 12 months how often did you have to see someone else when you wanted to see your personal doctor or nurse?			please select Never Sometimes Frequently
17. Are you able to get to your appointments when you choose?			please select Never Sometimes Always
18. Is there anything our practice can do to improve the care and services for you?			please select No, I’m satisfied with everything Yes, some things can be improved Yes, many things can be improved
18a. Please specify improvement:
19. Did you have any good or bad surprises while receiving your care?			please select Good Bad No surprises
19a. Please describe:
20. Are our hours of operation meeting your needs?			please select Yes No \
20a. If No, what hours would you like us to be open?
21. Is there enough room for Patient Parking?			please select Yes No \
About You: Please let us know a little about your health. This is only for demographic purposes only, and we are not requesting your name or address information.
22. In general, how would you rate your overall health?			please select Excellent Very good Good Fair Poor
23. What is your age?			please select Under 25 years 25 – 44 years 45 – 64 years 65 years or older
24. What is your gender?			please select Female Male
25. Are you Native American?			please select Native American Non-Native American

Sources: Medical Outcomes Study (MOS) Visit-Specific Questionnaire (VSQ), 1993
Patient Utilization Questions, Dartmouth Medical School