Who is your child's pediatrician?
The questions in this survey will refer to the provider you select as "this provider." Please think of that person as you answer the survey.
Dr. Joel
Dr. Meri
Dr. Eve
1. Our records show that your child got care from this provider in the last 6 months. Is that right?
*
Yes
No
2. Is this the provider you usually see if your child needs a check-up, has a health problem, or gets sick or hurt?
*
Yes
No
3. How long has your child been going to this provider?
*
Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more
4. In the last 6 months, how many times did your child visit this provider for care?
*
None
1
2
3
4
5 to 9
10 or more times
5. In the last 6 months, did you ever stay in the exam room with your child during a visit to this provider?
*
Yes -> If Yes, skip to #7
No
6. Did this provider give you enough information about what was discussed during the visit when you were not there?
Yes -> if Yes, go to #10
No -> If No, go to #10
7. Is your child able to talk with providers about his or her health care?
Yes
No -> If No, got to #10
8. In the last 6 months, how often did this provider explain things in a way that was easy for your child to understand?
Never
Sometimes
Usually
Always
9. In the last 6 months, how often did this provider listen carefully to your child?
Never
Sometimes
Usually
Always
10. Did this provider tell you that you needed to do anything to follow up on the care your child got during the visit?
Yes
No -> If No, go to #12
11. Did this provider give you enough information about what you needed to do to follow up on your child's care?
Yes
No
12. In the last 6 months, did you contact this provider's office to get an appointment for your child for an illness, injury, or condition that needed care right away?
*
Yes
No -> If No, go to #14
13. In the last 6 months when you contacted this provider's office to get an appointment for care your child needed right away, how often did you get an appointment as soon as your child needed?
Never
Sometimes
Usually
Always
14. In the last 6 months, did you make any appointments for a check-up or routine care for your child with this provider?
*
Yes
No -> If No, go to #16
15. In the last 6 months, when you made an appointment for a check-up or routine care for your child with this provider, how often did you get an appointment as soon as your child needed?
Never
Sometimes
Usually
Always
16. In the last 6 months, did you contact this provider's office with a medical question about your child during regular office hours?
*
Yes
No -> If no, go to #18
17. 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?
Never
Sometimes
Usually
Always
18. In the last 6 months, how often did this provider explain things about your child's health in a way that was easy to understand?
Never
Sometimes
Usually
Always
19. In the last 6 months, how often did this provider listen to you carefully?
Never
Sometimes
Usually
Always
20. In the last 6 months, how often did this provider seem to know the important information about your child's medical history?
Never
Sometimes
Usually
Always
21. In the last 6 months, how often did this provider show respect for what you had to say?
Never
Sometimes
Usually
Always
22. In the last 6 months, how often did this provider spend enough time with your child?
Never
Sometimes
Usually
Always
23. In the last 6 months, did this provider order a blood test, x-ray, or other test for your child?
*
Yes
No -> If no, go to #25
24. In the last 6 months, when this provider ordered a blood test, x-ray, or other test for your child, how often did someone from this provider's office follow up to give you those results?
Never
Sometimes
Usually
Always
25. 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?
*
0 Worst provider possible
1
2
3
4
5
6
7
8
9
10 Best provider possible
26. In the last 6 months, how often were clerks and receptionists at this office as helpful as you thought they should be?
*
Never
Sometimes
Usually
Always
27. In the last 6 monthsm how often did clerks and receptionists at this provider's office treat you with courtesy and respect?
*
Never
Sometimes
Usually
Always
28. In general, how would you rate your child's overall health?
*
Excellent
Very Good
Good
Fair
Poor
29. In general, how would you rate your child's overall mental or emotional health?
*
Excellent
Very Good
Good
Fair
Poor
30. What is your child's age?
*
Less than 1 year old
Older than 1 year old (Please enter age below)
Please enter your child's age.
31. Is your child male or female?
Male
Female
32. Is your child of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
33. What is your child's race? Mark one or more.
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaskan Native
Other
34. What is your age?
Under 18
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
35. What ist he highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year college
4-year college graduate
More than 4-year college degree
36. How are you related to the child?
Mother or father
Grandparent
Aunt or uncle
Older brother or sister
Other relative
Legal guardian
Someone else
37. Did someone help you complete this survey?
Yes -> If yes, please answer #38
No
38. How did that person help you?
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
OPTIONAL - Tell us your name
First Name
Last Name
OPTIONAL - Provide additional comments for Dr. Joel, Dr. Meri or Dr. Eve
OPTIONAL - We would like to update the patient and family testimonials on our website. If you would like to contribute a testimonial that we may use, please use the space below. Thank you!