Gastroenterology Associates of Colorado Springs, LLP Survey

1. Ease of making your appointment

	Poor	Fair	Good	Very Good	Excellent
Check one	*Ease of making your appointment Check one Poor	Check one Fair	Check one Good	Check one Very Good	Check one Excellent

2. Appointment available within a reasonable amount of time

	Poor	Fair	Good	Very Good	Excellent
Check one	*Appointment available within a reasonable amount of time Check one Poor	Check one Fair	Check one Good	Check one Very Good	Check one Excellent

3. Efficiency of check-in process

	Poor	Fair	Good	Very Good	Excellent
Check one	*Efficiency of check-in process Check one Poor	Check one Fair	Check one Good	Check one Very Good	Check one Excellent

4. Professionalism of our receptionist

	Poor	Fair	Good	Very good	Excellent
Check one	*Professionalism of our receptionist Check one Poor	Check one Fair	Check one Good	Check one Very good	Check one Excellent

5. Waiting time prior to seeing a physician/nurse practitioner

	Poor	Fair	Good	Very good	Excellent
Check one	*Waiting time prior to seeing a physician/nurse practitioner Check one Poor	Check one Fair	Check one Good	Check one Very good	Check one Excellent

6. Keeping you informed if your appointment time was delayed

	Poor	Fair	Good	Very Good	Excellent	N/A
Check one	*Keeping you informed if your appointment time was delayed Check one Poor	Check one Fair	Check one Good	Check one Very Good	Check one Excellent	Check one N/A

7. Professionalism of the Medical Assistant/Nurse

	Poor	Fair	Good	Very Good	Excellent	N/A
Check one	*Professionalism of the Medical Assistant/Nurse Check one Poor	Check one Fair	Check one Good	Check one Very Good	Check one Excellent	Check one N/A

8. The physician/nurse practitioner listening to you and taking time to answer questions

	Poor	Fair	Good	Very Good	Excellent
Check one	*The physician/nurse practitioner listening to you and taking time to answer questions Check one Poor	Check one Fair	Check one Good	Check one Very Good	Check one Excellent

9. Who was your appointment with?

Who was your appointment with? Mitchell

Lewey

Meister

Folan

Iwata

Krishnan

Cindy Billock, NP

Trish Sanford, NP

Sonja Griffith, NP

Kathy Genoshe, NP

10. Responsiveness to requests for medication refills

	Poor	Fair	Good	Very Good	Excellent	N/A
Check one	*Responsiveness to requests for medication refills Check one Poor	Check one Fair	Check one Good	Check one Very Good	Check one Excellent	Check one N/A

11. Your test results reported in a reasonable amount of time

	Poor	Fair	Good	Very Good	Excellent	N/A
Check one	*Your test results reported in a reasonable amount of time Check one Poor	Check one Fair	Check one Good	Check one Very Good	Check one Excellent	Check one N/A

12. Your overall satisfaction with the quality of medical care you received

	Poor	Fair	Good	Very Good	Excellent
Check one	*Your overall satisfaction with the quality of medical care you received Check one Poor	Check one Fair	Check one Good	Check one Very Good	Check one Excellent

13. IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT:

IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT:

14. Would you recommend the physician and/or nurse pratitioner to others?

Would you recommend the physician and/or nurse pratitioner to others? Yes	No
Please tell us why

15. Have you been to our office before?

Have you been to our office before? Yes

16. If yes to question 15-was the experience

If yes to question 15-was the experience Better than the last time	the same as the last time	worse than the last time
In What way?

17. Date of your appointment

	MM		DD		YYYY
MM/DD/YYYY	Date of your appointment MM/DD/YYYY Month	/	Day	/	Year

18. Name (optional):

Name (optional):

19. Your age

Your age Under 18

19-30

31-40

41-50

51-60

Over 60

Gastroenterology Associates of Colorado Springs, LLP

1. Patient Care Improvement Survey