2a. Does your child’s doctor listen to your concerns?
Yes
No

b. Does he/she ask you to share your knowledge as the caregiver of a child with special needs?
Yes
No
Please explain

3.When you call the office does the staff: 
a. Know whom you and your child are?  Yes  No
b. Recognize and accommodate your child’s special needs?  Yes  No
c. Work with you on requests for prior approvals, medications and letters you may need written?  Yes  No

4. Do you have a written health care plan that was developed by your doctor or his staff and your self?
Yes
No

If yes, how often is it reviewed?

5. Does anyone in the practice give you information on resources available in your community and/or additional services available for your child?
Yes
No

If so, who?

6. If your child is 14 or over, has your physician begun to discuss the process of medical transition (moving to adult health care) with you?
Yes
No
Please explain

 

7. Are your family’s culture and values acknowledged and respected?
Yes
No
Please explain

8. Please share one of your child’s physician’s best qualities.

9. Is there anything you think needs improvement in the practice?<

Age of your child

Diagnosis

Zip Code

(OPTIONAL)What is the racial/ethnic background with which you most closely identify?
White, Non-Hispanic
African American
Hispanic
Native American 
Asian<
Other, please specify

If you feel your child’s primary care physician is already providing a “medical home”, would you like to share his/her name with us?

Would you like to be an advisor to the Department of Public Health on the subject of Medical Home?
Yes
No

Is there another health issue you would like to work on?

If so, please share with us your:

Name:

Address:

City

State

Zip Code

Phone number:

E-mail address: (required)

Additional Comments: