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DRAFT Patient Survey Contact Fraser Northwest [email protected] This survey is being conducted by the physicians of the Fraser Northwest Division of Family Practice who provide care to patients in the TriCities, New Westminster and North Burnaby. We are collecting this information to better understand the healthcare experiences and needs of our patients. Your answers will help us try to make the health system work better. This survey is anonymous. Thank you for taking the time to complete it! How old are you? 18 to 24 years 25 to 34 years 35 to 44 years 45 to 54 years 55 to 64 years 65 to 75 years over 75 Do you have any chronic health conditions? Yes No Unsure Are you on any medication prescribed by a doctor regularly because of a chronic health condition? Yes No Unsure Are you on FIVE OR MORE regular medications prescribed by a doctor? Yes No Unsure How confident are you that you can control and manage your health problems? Very confident Somewhat confident Not confident Unsure In the past 12 months, has a doctor or pharmacist Yes No Unsure Reviewed with you all the medications you take? Given you a written list of all your prescribed medications? How many times do you think you have visited each of the following for medical care in the past 12 months? 0 1-2 3-4 5-6 7-8 9-10 11-12 >12 Your family doctor An emergency room A walk-in clinic A specialist Have you been hospitalized overnight in the past 12 months? Yes No Unsure The last time I went to the hospital emergency department it was for a condition that could have been treated by my regular doctor had they been available Yes No Unsure Not applicable When I left the hospital, the hospital made sure I had follow-up care with with a doctor or other health care professional Yes No Unsure Not applicable After being in the hospital, my regular doctor did not seem informed and up to date about the care I received in the hospital Yes No Unsure Not applicable How easy or difficult is it for you to get medical care in the evenings, on weekends, or holidays without going to the hospital emergency department? Very easy Somewhat easy Somewhat difficult Very difficult Do you have a regular family doctor? No Yes Unsure How long have you had your family doctor? Less than 6 months 6 months to a year Between 1 and 2 years Between 2 and 5 years Between 5 and 10 years More than 10 years My thoughts and feelings are important to my family doctor Strongly Agree Agree Neutral Disagree Strongly Disagree Unsure The last time you needed care for a NON-URGENT health problem (such as a prescription renewal or minor ailment), how quickly were you able to be seen by your regular family doctor (or his or her alternate)? On the same day The next day In 2 to 3 days In 4 to 5 days In 6 to 7 days After more than a week Never able to see a doctor Don’t know The last time you needed care for an URGENT health problem (such as a fever, or injury), how quickly were you able to be seen by your regular family doctor (or his or her alternate)? On the same day The next day In 2 to 3 days In 4 to 5 days In 6 to 7 days After more than a week Never able to see a doctor Don’t know When you faced challenges in getting in to see your family doctor for an URGENT health problem, what did you do? CHECK AS MANY AS APPLY Went to a walk-in clinic Went to the emergency room Sought care from a different category of provider such as physiotherapist, chriopractor etc. Called the nurseline Did one or more of the above and ALSO saw my family doctor about the problem Waited for the appointment Did not get care When you require care from other doctors or services (such as an appointment with a specialist), how often does someone in your family doctor's practice help coordinate or arrange that care? Always Often Sometimes Rarely Never Have not needed care outside my family doctor's office Unsure When you need care or treatment, how often does your family doctor Always Often Sometimes Rarely Never unsure Involve you as much as you want to be in decisions about your care and treatment? Give you clear instructions about symptoms to watch for and when to seek further care or treatment? Overall, how do you rate the medical care that you have received in the past 12 months from your family doctor’s practice? Excellent Very Good Good Fair Poor Unsure During the past 2 weeks, what was the hardest physical activity you could do for at least 2 minutes? Very heavy, (for example) run, at a fast pace Heavy, (for example) jog, at a slow pace Moderate, (for example) walk, at a fast pace Light, (for example) walk, at a medium pace Very Light, (for example) walk, at a slow pace or not able to walk During the past 2 weeks, Not at all How much have you been bothered by Slightly Moderately Quite a bit Extremely emotional problems such as feeling anxious, depressed, irritable or downhearted and sad? Has your physical and emotional health limited your social activities with family, friends, neigbours or groups During the past 2 weeks, how would you rate your health in general? Excellent Very Good Good Fair Poor Gender M F Which of the following categories best describes your total household income before taxes? Less than $40,000 $40,000 to less than $60,000 $60,000 to less than $80,000 $80,000 to less than $100,000 $100,000 to less than $125,000 $125,000 or more Unsure What are the first three digits of your postal code? What is the highest level of education you have attained? Grade school or some high school Completed high school Post secondary technical school Some college or university Completed college diploma Completed university degree Post-grad degree (Masters, Ph.D, etc.) Thanks for taking our survey!
