PFE Survey

Date Submitted

1. Which of the following best describes you? I am a Medicare beneficiary.
I am a family member or caregiver.
I am an individual and the above categories do not apply to me.

2. What is your ZIP code? (Residents of Puerto Rico and the U.S. Virgin Islands should enter 00 and then your 3-digit ZIP code.)

3. In which state or territory do you live?

4. Have you taken this survey before? Yes
No

6. Do you read the information you receive with your new prescription medication to learn about side effects and precautions or warnings? AlwaysMost of the time SometimesNever

7. Do you read information about your medication(s) on the internet? AlwaysMost of the time SometimesNever

8. Do you bring a list of questions or concerns with you to your primary health care provider’s visit that you want to ask your primary health care provider? AlwaysMost of the time SometimesNever

9. Do you leave your primary health care provider’s office feeling that all of your concerns or questions have been fully answered? AlwaysMost of the time SometimesNever

10. Do you ask your primary health care provider questions or read about a medical test or procedure before it happens to learn more about it? AlwaysMost of the time SometimesNever

11. Do you talk with your primary health care provider about your options if you need tests or follow-up care? AlwaysMost of the time SometimesNever

In thinking about your relationship with your primary health care provider, tell us if the following statements always, most of the time, sometimes or never happen.

12. My primary health care provider listens to what I have to say about my symptoms and concerns. AlwaysMost of the time SometimesNever

13. My primary health care provider explains things to me in terms that I can easily understand. AlwaysMost of the time SometimesNever

14. I can call my primary health care provider’s office to get medical advice when I need it. AlwaysMost of the time SometimesNever

15. Rate your current satisfaction with your primary health care provider on a scale of 0 to 10, where 0 is not satisfied and 10 is completely satisfied. 0 (Not Satisfied)12345678910 (Satisfied)

Patient and Family Assessment of Activation and Satisfaction

For each question below, do you always, most of the time, sometimes or never do the following? Please answer these questions as truthfully and accurately as possible.

In thinking about your relationship with your primary health care provider, tell us if the following statements always, most of the time, sometimes or never happen.

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