Feedback - Christian Global Medical Healthcare Incorporated

What is your age?

What is your race/ethnicity?

Asian
Pacific Islander
Black/African American
American Indian/Alaska Native
White (Not Hispanic or Latino)
Hispanic or Latino
Biracial
Multiracial

What is your gender?

Male
Female
Transgender

What is your Religion?

Christianity
Islam
Hinduism
Buddhism
Satanic Worship
African Traditional Religion
Atheism
Native American Religion
Other

Other religion

Have you been seen in our office before?

Yes
No

Date seen

Ease of getting access to care: How quickly were you able to get appointment to be seen at this practice?

Ease of getting access to care: Rate your waiting time in the waiting room

How long did you wait to be seen today?

Facility: How neat and clean is the Facility?

You were easily served the Health Insurance Portability and Accountability Act (HIPAA) notice, your rights, and your responsibilities.

Rate the professional appearance (Hair, skin, clothes, shoes, odors) of the staff

Reception at front desk?/Front Office: How was the courtesy of the staff?

Payment: How well did the Staff explain payment options for your charges?

The rooming Staff took enough time listening to you in a friendly caring manner.

The provider listened to you before explaining the care process for managing your health issues in words that you understand.

Did you receive services here at this practice that you were unable to access previously elsewhere?

Yes
No

What type of services did you receive here?

What, if any, community resources were you connected with today?

Examples: DHS, Food Pantries, Senior Services, Suicide Hotline, Employment agencies, Housing programs, Heating Assistance, Homeless Shelters, Schools, WIC, Summer programs, Big Brother Big Sister, Cradle Care, Head Start, second hand clothing stores, etc.

Are you satisfied with the services that you received today?

Highly Satisfied
Mostly Satisfied
Fairly Satisfied
Likely Satisfied
Not Satisfied

What is the likelihood of you referring your relatives, friends, workmates, neighbors, and others to this practice? Please choose the answer the best suits you.

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