Thank you for taking the time to complete this survey. Please answer the following questions to the best of your ability.

Gracias por tomar el tiempo para responder a esta encuesta. Por favor conteste las siguientes preguntas lo mejor que pueda.

Date you Received Care
January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029

Please enter your responses below:

Por favor marque sus respuestas en las siguientes preguntas:

1. What service were you here for? What service were you here for?

   Respiratory Therapy Pulmonary Rehab Cardiac Rehab Stress Test Pulmonary Function Tests EKG Other

2. How was the Quality of Service you received from your Respiratory Care Team? How was the Quality of Service you received from your Respiratory Care Team?

   Very Good Muy bueno

   Good Bueno

   Fair Regular

   Poor Malo

   Very Poor Muy malo

   n/a n/a

3. Were you seen/scheduled in a timely matter? Were you seen/scheduled in a timely matter?

   Yes No If not, why

4. How would you rate our facility? How would you rate our facility?

   Very Good Muy bueno

   Good Bueno

   Fair Regular

   Poor Malo

   Very Poor Muy malo

   n/a n/a

5. Would you recommend our facility to your friends? Would you recommend our facility to your friends?

   Always Siempre

   Almost Always Casi siempre

   Sometimes a veces

   Rarely Raramente

   Never Nunca

   n/a n/a

6. How would you rate your overall experience? How would you rate your overall experience?

   Very Good Muy bueno

   Good Bueno

   Fair Regular

   Poor Malo

   Very Poor Muy malo

   n/a n/a

7. Other comments Other comments