Patient Care Survey - GCC

Please tell us about your clinic and /or surgical experience by answering the following questions.

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* What is your physician's name?

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* Rate how well your physician accomplished the following:

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Made me feel comfortable (i.e., Caring and friendly attitude)	Made me feel comfortable (i.e., Caring and friendly attitude) Excellent	Made me feel comfortable (i.e., Caring and friendly attitude) Very Good	Made me feel comfortable (i.e., Caring and friendly attitude) Average	Made me feel comfortable (i.e., Caring and friendly attitude) Poor	Made me feel comfortable (i.e., Caring and friendly attitude) Failed	Made me feel comfortable (i.e., Caring and friendly attitude) N/A (No contact/Does not apply)

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* .

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Paid attention to me (i.e., looked at me, listened carefully)	Paid attention to me (i.e., looked at me, listened carefully) Excellent	Paid attention to me (i.e., looked at me, listened carefully) Very Good	Paid attention to me (i.e., looked at me, listened carefully) Average	Paid attention to me (i.e., looked at me, listened carefully) Poor	Paid attention to me (i.e., looked at me, listened carefully) Failed	Paid attention to me (i.e., looked at me, listened carefully) N/A (No contact/Does not apply)

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* .

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Addressed my questions / concerns	Addressed my questions / concerns Excellent	Addressed my questions / concerns Very Good	Addressed my questions / concerns Average	Addressed my questions / concerns Poor	Addressed my questions / concerns Failed	Addressed my questions / concerns N/A (No contact/Does not apply)

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* .

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Spent the right amount of time with me	Spent the right amount of time with me Excellent	Spent the right amount of time with me Very Good	Spent the right amount of time with me Average	Spent the right amount of time with me Poor	Spent the right amount of time with me Failed	Spent the right amount of time with me N/A (No contact/Does not apply)

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* .

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Respected my dignity / privacy during the exam	Respected my dignity / privacy during the exam Excellent	Respected my dignity / privacy during the exam Very Good	Respected my dignity / privacy during the exam Average	Respected my dignity / privacy during the exam Poor	Respected my dignity / privacy during the exam Failed	Respected my dignity / privacy during the exam N/A (No contact/Does not apply)

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* .

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Explained my medical condition and treatment plan	Explained my medical condition and treatment plan Excellent	Explained my medical condition and treatment plan Very Good	Explained my medical condition and treatment plan Average	Explained my medical condition and treatment plan Poor	Explained my medical condition and treatment plan Failed	Explained my medical condition and treatment plan N/A (No contact/Does not apply)

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* .

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Made an effort to include me in decisions about my treatment	Made an effort to include me in decisions about my treatment Excellent	Made an effort to include me in decisions about my treatment Very Good	Made an effort to include me in decisions about my treatment Average	Made an effort to include me in decisions about my treatment Poor	Made an effort to include me in decisions about my treatment Failed	Made an effort to include me in decisions about my treatment N/A (No contact/Does not apply)

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* .

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Provided instructions on my medications / activities	Provided instructions on my medications / activities Excellent	Provided instructions on my medications / activities Very Good	Provided instructions on my medications / activities Average	Provided instructions on my medications / activities Poor	Provided instructions on my medications / activities Failed	Provided instructions on my medications / activities N/A (No contact/Does not apply)

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* .

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Was respectful / courteous to me and my family when talking with us	Was respectful / courteous to me and my family when talking with us Excellent	Was respectful / courteous to me and my family when talking with us Very Good	Was respectful / courteous to me and my family when talking with us Average	Was respectful / courteous to me and my family when talking with us Poor	Was respectful / courteous to me and my family when talking with us Failed	Was respectful / courteous to me and my family when talking with us N/A (No contact/Does not apply)

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* .

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Talked in a way that was understandable to me	Talked in a way that was understandable to me Excellent	Talked in a way that was understandable to me Very Good	Talked in a way that was understandable to me Average	Talked in a way that was understandable to me Poor	Talked in a way that was understandable to me Failed	Talked in a way that was understandable to me N/A (No contact/Does not apply)

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* .

	Excellent	Very Good	Average	Poor	Failed	N/A (No contact/Does not apply)
Checked to be sure that I understood everything	Checked to be sure that I understood everything Excellent	Checked to be sure that I understood everything Very Good	Checked to be sure that I understood everything Average	Checked to be sure that I understood everything Poor	Checked to be sure that I understood everything Failed	Checked to be sure that I understood everything N/A (No contact/Does not apply)

Patient Care Survey - GCC

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* What is your physician's name?

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* Rate how well your physician accomplished the following:

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* Would you recommend this doctor to your family and friends?

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* Please share any comments regarding your experience: