In an ongoing effort to provide the highest caliber of health care to the communities we serve, we would like you to know if we are meeting your needs and expectations. Please take a few moments to give us your feedback, it will be used as an invaluable part of our Performance Improvement Program, thus enabling Grand River Hospital District to better serve you, our district members. Thank you.

1.	In the past 12 months, have you received health care services from Grand River Hospital District?

Yes      No

2.	If you answered "yes" to #1, in what capacity?

Nursing Home / Care Center Grand River Primary Care Services Battlement Mesa Medical Center Services Hospital Inpatient Services Outpatient Specialty Services Surgical Services Emergency Department Services Radiology / Lab, X-Ray, CT scan, MRI scan, Mammography Respiratory or Cardiopulmonary Services Physical Therapy Other

3.	Are you satisfied with the services we are providing?

Yes      No

4.	What suggestions do you have for improvement?

5.	Please check all services you use at Grand River Medical Center:

Emergency Services / Level IV Trauma Inpatient Unit Inpatient and Outpatient Surgery Physical, Speech, and Occupational Therapy Pediatrics Family Medicine Internal Medicine Geriatrics Prenatal / Postnatal Care Cardiopulmonary Services Sleep Studies MRI Scan Bone Density Scan Ultrasound Mammography X-Ray CT Scan Laboratory Spinal Block Urology Ophthalmology Cardiology Neurology Orthopaedic Surgery Ear, Nose, and Throat Gastroenterology (endoscopy / colonoscopy) Plastic / Reconstructive Surgery Nutritional Counseling Weight Management Program Meals on Wheels Community Education Programs

6.	If you were not aware of the many services offered by Grand River Hospital District, please comment on how we can keep you informed as to what we have to offer our community:

7.	Please check all services you would use at Grand River Medical Center if they were offered:

Cardiac Rehabilitation Chemotherapy Obstetrics Dialysis Dermatology Gynecology Oncology Oral Surgery Wellness Program Acupuncture Massage Therapy Herbal Virtual Endoscopy Nuclear Medicine Support Group for Other

8.	In the past 12 months, have you visited any of the following health care practitioners:

have used approx. times per month interested in more information not interested Chiropractor Acupuncturist Reflexologist Homeopath Naturopath (nutritionist) Massage Therapist Hospital Staff   Other

9.	What other services have you chosen in the past 12 months?

Exercise Program Physical Therapy Support Groups Tai Chi Other   Types: Wellness Workshops/Classes such as Energy for Life, Herbal Classes, and General Health Classes. Please list:

10.	What types of nutritional supplements have you taken in the past 12 months?

Vitamins Herbs Homeopathics

11.	Do you take prescription drugs?

Yes    Number of medications taken: No

12.	What does "wellness" mean to you?

I would like to set up an appointment to discuss the feedback I have expressed in this survey.

I would appreciate receiving a phone call to discuss the feedback I have expressed in this survey.

THANK YOU FOR TAKING THE TIME TO ANSWER THESE QUESTIONS. WE GREATLY APPRECIATE YOUR ASSISTANCE!

Optional:

Your Name: Your Address: Your Phone Number:

If you have any questions, please contact:

Kris Daler, Director of Public Relations Grand River Hospital District P.O. Box 912 Rifle, CO 81650 970.625.6433 kdaler@grhd.org