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Table 1 Complete questionnaire and multiple-choice options

From: An evaluation of Alberta retina health service delivery in an office setting: a cross-sectional survey of patient experience

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
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