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Pikes Peak Endoscopy and Surgery Center, LLC 21 questions

1. Ease of Scheduling your procedure

	Poor	Fair	Good	Very Good	Excellent
Please rate	*Ease of Scheduling your procedure Please rate Poor	Please rate Fair	Please rate Good	Please rate Very Good	Please rate Excellent

2. Efficiency of check-in process

	Poor	Fair	Good	Very Good	Excellent
Please rate	*Efficiency of check-in process Please rate Poor	Please rate Fair	Please rate Good	Please rate Very Good	Please rate Excellent

3. Waiting time before the procedure

	Poor	Fair	Good	Very good	Excellent
Please rate	*Waiting time before the procedure Please rate Poor	Please rate Fair	Please rate Good	Please rate Very good	Please rate Excellent

4. The cleanliness and ambiance of the facility

	Poor	Fair	Good	Very good	Excellent
Please rate	*The cleanliness and ambiance of the facility Please rate Poor	Please rate Fair	Please rate Good	Please rate Very good	Please rate Excellent

5. The professionalism of our receptionist

	Poor	Fair	Good	Very Good	Excellent
Please rate	*The professionalism of our receptionist Please rate Poor	Please rate Fair	Please rate Good	Please rate Very Good	Please rate Excellent

6. The professionalism of our nursing staff

	Poor	Fair	Good	Very Good	Excellent
Please rate	*The professionalism of our nursing staff Please rate Poor	Please rate Fair	Please rate Good	Please rate Very Good	Please rate Excellent

7. The empathy or enthusiasm of our nursing staff

	Poor	Fair	Good	Very Good	Excellent
Please rate	*The empathy or enthusiasm of our nursing staff Please rate Poor	Please rate Fair	Please rate Good	Please rate Very Good	Please rate Excellent

8. The staff taking time to answer questions before and after the procedure

	Poor	Fair	Good	Very Good	Excellent
Please rate	*The staff taking time to answer questions before and after the procedure Please rate Poor	Please rate Fair	Please rate Good	Please rate Very Good	Please rate Excellent

9. Were the discharge instructions easy to understand?

Were the discharge instructions easy to understand?   Yes No

10. The feeling your physician listened to you

	Poor	Fair	Good	Very Good	Excellent
Please rate	*The feeling your physician listened to you Please rate Poor	Please rate Fair	Please rate Good	Please rate Very Good	Please rate Excellent

11. The physician taking time to answer your questions before and after the procedure

	Poor	Fair	Good	Very good	Excellent
Please rate	*The physician taking time to answer your questions before and after the procedure Please rate Poor	Please rate Fair	Please rate Good	Please rate Very good	Please rate Excellent

12. How friendly was your Anesthesiologist?

How friendly was your Anesthesiologist?   Not at all

Somewhat

Was friendly

Was very friendly

13. Your level of comfort during the procedure

	Poor	Fair	Good	Very Good	Excellent
Please rate	*Your level of comfort during the procedure Please rate Poor	Please rate Fair	Please rate Good	Please rate Very Good	Please rate Excellent

14. Which physician performed your procedure?

Which physician performed your procedure?   Mitchell

Lewey

Meister

Folan

Iwata

Krishnan

Stangl

15. Your overall satisfaction with our facility

	Poor	Fair	Good	Very Good	Excellent
Please rate	*Your overall satisfaction with our facility Please rate Poor	Please rate Fair	Please rate Good	Please rate Very Good	Please rate Excellent

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

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

17. Is there any particular person(s) that made your stay better or worse and why?

Is there any particular person(s) that made your stay better or worse and why?

18. 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:

19. Date of your procedure

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

20. Name (optional):

Name (optional):

21. Your age

Your age   Under 18

19-30

31-40

41-50

51-60

Over 60