Survey

Dear Patient: According to our records, you recently visited the provider med above. Please tell us your opinion about the service you received from this provider. Your responses will be kept strictly confidential. Thanks for your help.

FILL IN THE FOLLOWING NECESSARY CREDENTIALS


PLEASE RATE THE FOLLOWING:

  Excellent Very Good Good Fair Poor Does not apply

A. YOUR APPOINTMENT:

           
             
1. Ease of making appointments by phone   5   4   3   2   1   NA
             
2. Appointment available within a reasoble amount of time   5   4   3   2   1   NA
             
3. Getting care for illness/injury as soon as you want it   5   4   3   2   1   NA
             
4. Getting after-hours care when you needed it   5   4   3   2   1   NA
             
5. The efficiency of the check-in process   5   4   3   2   1   NA
             
6. Waiting time in the reception area   5   4   3   2   1   NA
             
7. Waiting time in the exam room   5   4   3   2   1   NA
             
8. Keeping you informed if your appointment time was delayed   5   4   3   2   1   NA
             
9. Ease of getting a referral when you needed one   5   4   3   2   1   NA

 

           

B. OUR STAFF:

           
             
1. The courtesy of the person who took your call   5   4   3   2   1   NA
             
2. The friendliness and courtesy of the receptionist   5   4   3   2   1   NA
             
3. The caring concern of our nurses/medical assistants   5   4   3   2   1   NA
             
4. The helpfulness of the people who assisted you with billing or insurance   5   4   3   2   1   NA

 

           

C. OUR COMMUNICATION WITH YOU:

           
             
1. Your phone calls answered promptly   5   4   3   2   1   NA
             
2. Getting advice or help when needed during office hours   5   4   3   2   1   NA
             
3. Explation of your scheduled tests (if applicable)   5   4   3   2   1   NA
             
4 Your test results reported in a reasoble amount of time   5   4   3   2   1   NA
             
5. Effectiveness of our health information materials   5   4   3   2   1   NA
             
6. Our ability to return your calls in a timely manner   5   4   3   2   1   NA
             
7. Your ability to contact us after hours   5   4   3   2   1   NA
             
8. Your ability to obtain prescription refills by phone   5   4   3   2   1   NA

 

           

D. YOUR VISIT WITH THE PROVIDER:
(Doctor, Nurse Practitioner)

           
             
1. Willingness to listen carefully to your symptoms   5   4   3   2   1   NA
             
2. Ask questions regarding your health history   5   4   3   2   1   NA
             
3. Explains test that he/she ordered   5   4   3   2   1   NA
             
4. Discusses treatment options with you, including the
the expected course of treatment
  5   4   3   2   1   NA
             
5. Explains drugs and other treatments (for example, psychotherapy)
their expected effects, and possible side effects
  5   4   3   2   1   NA
             
6. Discusses the treatment costs, insurance, and payment
options with you
  5   4   3   2   1   NA
             
7. Encourages you to ask questions about your treatment   5   4   3   2   1   NA
             
8. Answers questions to your satisfaction   5   4   3   2   1   NA
             
9. Gives you advice on what to do if symptoms persist or worsen   5   4   3   2   1   NA
             
10.Refers you to another specialist when necessary   5   4   3   2   1   NA
             
11.Tells you when to schedule a return visit   5   4   3   2   1   NA
             
12.Treats you in a professiol manner   5   4   3   2   1   NA

 

           

E. OUR FACILITY:

           
             
1. Hours of operation convenient for you   5   4   3   2   1   NA
             
2. Overall comfort   5   4   3   2   1   NA
             
3. Adequate parking   5   4   3   2   1   NA
             
4. Sigge and directions easy to follow   5   4   3   2   1   NA

 

           

F. YOUR OVERALL SATISFACTION WITH:

           
             
1. Our practice   5   4   3   2   1   NA
             
2. The quality of your medical care   5   4   3   2   1   NA
             
3. Overall rating of care from your provider or nurse   5   4   3   2   1   NA
 
 
 
 
 
WOULD YOU RECOMMEND THE PROVIDER TO OTHERS?
IF NO, PLEASE TELL US WHY:
       
 
 
IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES
TO YOU, PLEASE TELL US ABOUT IT:
       

SOME INFORMATION ABOUT YOU:

           
       
GENDER YOUR AGE ARE YOU:
 Male     Female
 
 
Are You Human ?      Yes