Patient Satisfaction Survey

Your Visit
1

Your appointment was with:
2

Your age:
3

Are you a:

Your Appointment
4

Ease of making appointments by phone

PoorFairGoodExcellentN/A
1
2
3
4
5
5

Appointment available within a reasonable amount of time

PoorFairGoodExcellentN/A
1
2
3
4
5
6

Getting after-hours assistance when you needed it

PoorFairGoodExcellentN/A
1
2
3
4
5
7

The efficiency of the check-in process

PoorFairGoodExcellentN/A
1
2
3
4
5
8

Waiting time in the reception room

PoorFairGoodExcellentN/A
1
2
3
4
5
9

Waiting time in the exam room

PoorFairGoodExcellentN/A
1
2
3
4
5
10

Keeping you informed if your appointment time was delayed

PoorFairGoodExcellentN/A
1
2
3
4
5

Our Staff
11

The courtesy of the person who took your call

PoorFairGoodExcellentN/A
1
2
3
4
5
12

The friendliness and courtesy of the receptionist

PoorFairGoodExcellentN/A
1
2
3
4
5
13

The caring concern of our nurses/medical assistants

PoorFairGoodExcellentN/A
1
2
3
4
5
14

The helpfulness of the people who assisted you with billing or insurance

PoorFairGoodExcellentN/A
1
2
3
4
5

Our Communication With You
15

Your phone calls were answered promptly

PoorFairGoodExcellentN/A
1
2
3
4
5
16

Getting advice or help when needed during office hours

PoorFairGoodExcellentN/A
1
2
3
4
5
17

Explanation of your procedure (if applicable)

PoorFairGoodExcellentN/A
1
2
3
4
5
18

Your test results reported in a reasonable amount of time

PoorFairGoodExcellentN/A
1
2
3
4
5
19

Effectiveness of our health information materials

PoorFairGoodExcellentN/A
1
2
3
4
5
20

Our ability to return your calls in a timely manner

PoorFairGoodExcellentN/A
1
2
3
4
5
21

Your ability to contact us after hours for urgent concerns

PoorFairGoodExcellentN/A
1
2
3
4
5
22

Your ability to obtain prescription refills by phone

PoorFairGoodExcellentN/A
1
2
3
4
5

Your Visit With the Provider

(Doctor, Nurse Practitioner, Nurse or Other)
23

Willingness to listen carefully to you

PoorFairGoodExcellentN/A
1
2
3
4
5
24

Taking time to answer your questions

PoorFairGoodExcellentN/A
1
2
3
4
5
25

Quality of time spent with you

PoorFairGoodExcellentN/A
1
2
3
4
5
26

Explaining things in a way you could understand

PoorFairGoodExcellentN/A
1
2
3
4
5
27

Instructions regarding medication/follow-up care

PoorFairGoodExcellentN/A
1
2
3
4
5
28

The thoroughness of the examination

PoorFairGoodExcellentN/A
1
2
3
4
5
29

Advice given to you on ways to stay healthy

PoorFairGoodExcellentN/A
1
2
3
4
5