Table 1 Complete questionnaire and multiple-choice options
Questions | Response Choices |
|---|---|
1. Was this your first time at this clinic to see a retinal specialist? | Yes |
No | |
2. How long did you wait from the time of your referral until your visit to the specialist at this clinic? | Less than 1 week |
1–2 weeks | |
2 weeks-1 month | |
More than a month | |
3. How long did you wait until you were seen by the specialist on your visit today? | Less than 30 min |
30 min-1 h | |
1–2 h | |
More than 2 h | |
4. What is the name of the specialist you saw today? | [Physician Name] |
5. What is the reason for your visit at this clinic today? | New Retinal Issue |
Follow up | |
Scheduled Injection | |
Other | |
6. a. During visit today, did your specialist clearly explain your injection plan to you? | Yes definitely |
Yes somewhat | |
No not really | |
No definitely not | |
7. b. Did your retina specialist explain the Optical Coherence Tomography (OCT) test results to you? | Yes definitely |
Yes somewhat | |
No not really | |
No definitely not | |
8. c. Do you know what the risks associated with the injection are? | Yes definitely |
Yes somewhat | |
No not really | |
No definitely not | |
9. Have you received an injection for macular degeneration? | Yes |
No | |
10. How long was the wait between your referral and being seen by a retinal specialist? | Less than 1 week |
1–2 weeks | |
2 weeks-1 month | |
More than a month | |
11. Did you receive the injection on the same day you were first seen by the retinal specialist? | Yes |
No | |
12. What medication do you receive with your injection? | Eylea |
Lucentis | |
Avastin | |
I don’t know | |
13. Did you have a retinal detachment? | Yes |
No | |
a) How long was the wait between the referral for the retinal detachment and when you were seen by the retinal specialist? | [insert Answer] |
b) Did you have surgery on the same day as you were first seen by the retinal specialist? | Yes |
No | |
c) Were you referred for a retinal tear? | Yes |
No | |
14. Did your specialist spend enough time with you? | Yes definitely |
Yes somewhat | |
No not really | |
No definitely not | |
15. Do you feel that your specialist listened to you? | Yes definitely |
Yes somewhat | |
No not really | |
No definitely not | |
16. Did your specialist involve you in decisions about your care as much as you wanted? | Yes definitely |
Yes somewhat | |
No not really | |
No definitely not | |
17. How confident are you that you can manage your own health with the help of your specialist? | Very Confident |
Fairly Confident | |
Not Very Confident | |
Not Confident | |
18. Did your specialist provide you with informational materials (e.g. handouts) or talk to you about resources where you could find more information regarding your health? | Yes No |
19. Would you have liked to receive informational handouts or a list of information resources from your specialist? | Yes |
No | |
a) In what form would you have liked to receive information? | A Newsletter |
An Electronic newsletter | |
Web links (internet) | |
Paper Handout | |
20. Using any number from 1 to 5, where 1 is the poorest possible care experience and 5 is the best possible care experience, please select the number would you use to rate this clinic? | 1 |
2 | |
3 | |
4 | |
5 | |
21. Have you utilized the on-call services of the office? | Yes |
No | |
a) Have you called the clinic after-hours? | Yes |
No | |
b) Did the physician/clinic call you back in a timely fashion? | Yes |
No | |
c) Were you satisfied by the service provided? | Yes definitely |
Yes somewhat | |
No not really | |
No definitely not | |
22. Were you satisfied by the access to clinic information/medical advice after-hours? | Yes definitely |
Yes somewhat | |
No not really | |
No definitely not | |
23. Do you identify as....? | Female |
Male | |
Other (Specify) | |
24. How old are you? | Under 25 |
25–34 | |
35–44 | |
45–54 | |
55–64 | |
65–74 | |
75–85 | |
Older than 85 | |
25. Do you identify as...? | White |
Asian | |
First Nations | |
Black/ African American | |
Hispanic/Latino | |
Middle Eastern | |
Other | |
I’d rather not say | |
26. What is your postal code? This helps us understand how far you had to travel for health services. | [Postal Code] |
27. How did you come to your visit today? Please check all that apply | Bicycle |
Bus | |
Taxi | |
DATS | |
on foot | |
Train | |
Plane | |
Other | |
28. Did somebody have to accompany you on your visit today? | Yes |
No | |
29. Please provide us with feedback to help us improve future experiences at this clinic. | [Comment] |
30. Complete? | Complete |
Incomplete |