Patient Survey
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1. Date

	MM		DD		YYYY
Date of your office visit:	Date Date of your office visit: Month	/	Day	/	Year

2. Background Questions:

Background Questions: Patient's Sex:
Was this your first visit as a patient to our office?
Patient's Name (Optional):
Patient's age:
Email:

3. Please rate the following qualities of our receptionists:

	Very Poor	Poor	Fair	Good	Excellent
Helpfulness of the staff person you made appointment with	*Please rate the following qualities of our receptionists: Helpfulness of the staff person you made appointment with Very Poor	Helpfulness of the staff person you made appointment with Poor	Helpfulness of the staff person you made appointment with Fair	Helpfulness of the staff person you made appointment with Good	Helpfulness of the staff person you made appointment with Excellent
Ease of getting an appointment	Ease of getting an appointment Very Poor	Ease of getting an appointment Poor	Ease of getting an appointment Fair	Ease of getting an appointment Good	Ease of getting an appointment Excellent
Wait time to be seen by physician	Wait time to be seen by physician Very Poor	Wait time to be seen by physician Poor	Wait time to be seen by physician Fair	Wait time to be seen by physician Good	Wait time to be seen by physician Excellent
Courtesy of front desk staff	Courtesy of front desk staff Very Poor	Courtesy of front desk staff Poor	Courtesy of front desk staff Fair	Courtesy of front desk staff Good	Courtesy of front desk staff Excellent
How well billing and insurance questions were handled	How well billing and insurance questions were handled Very Poor	How well billing and insurance questions were handled Poor	How well billing and insurance questions were handled Fair	How well billing and insurance questions were handled Good	How well billing and insurance questions were handled Excellent

Other (please specify)

4. Please rate your Doctor Visit:

	Very Poor	Poor	Fair	Good	Excellent
Friendliness of the physician	*Please rate your Doctor Visit: Friendliness of the physician Very Poor	Friendliness of the physician Poor	Friendliness of the physician Fair	Friendliness of the physician Good	Friendliness of the physician Excellent
Your comfort level with the physician	Your comfort level with the physician Very Poor	Your comfort level with the physician Poor	Your comfort level with the physician Fair	Your comfort level with the physician Good	Your comfort level with the physician Excellent
Please rate the physician’s bedside manner	Please rate the physician’s bedside manner Very Poor	Please rate the physician’s bedside manner Poor	Please rate the physician’s bedside manner Fair	Please rate the physician’s bedside manner Good	Please rate the physician’s bedside manner Excellent
Your expectations met and concerns answered	Your expectations met and concerns answered Very Poor	Your expectations met and concerns answered Poor	Your expectations met and concerns answered Fair	Your expectations met and concerns answered Good	Your expectations met and concerns answered Excellent
Friendliness of nursing staff	Friendliness of nursing staff Very Poor	Friendliness of nursing staff Poor	Friendliness of nursing staff Fair	Friendliness of nursing staff Good	Friendliness of nursing staff Excellent
Comfort of your examining room	Comfort of your examining room Very Poor	Comfort of your examining room Poor	Comfort of your examining room Fair	Comfort of your examining room Good	Comfort of your examining room Excellent

Other (please specify)

5. Please rate our Scheduling Procedure:

	Very Poor	Poor	Fair	Good	Excellent
Ease of scheduling a procedure	*Please rate our Scheduling Procedure: Ease of scheduling a procedure Very Poor	Ease of scheduling a procedure Poor	Ease of scheduling a procedure Fair	Ease of scheduling a procedure Good	Ease of scheduling a procedure Excellent
Instructions given for procedure by staff	Instructions given for procedure by staff Very Poor	Instructions given for procedure by staff Poor	Instructions given for procedure by staff Fair	Instructions given for procedure by staff Good	Instructions given for procedure by staff Excellent
Courtesy of Surgical Coordinator	Courtesy of Surgical Coordinator Very Poor	Courtesy of Surgical Coordinator Poor	Courtesy of Surgical Coordinator Fair	Courtesy of Surgical Coordinator Good	Courtesy of Surgical Coordinator Excellent

Other (please specify)

6. Some Final Ratings:

	Very Poor	Poor	Fair	Good	Excellent
Décor and cheerfulness of Foot & Ankle Care	*Some Final Ratings: Décor and cheerfulness of Foot & Ankle Care Very Poor	Décor and cheerfulness of Foot & Ankle Care Poor	Décor and cheerfulness of Foot & Ankle Care Fair	Décor and cheerfulness of Foot & Ankle Care Good	Décor and cheerfulness of Foot & Ankle Care Excellent
Cleanliness of Foot & Ankle Care	Cleanliness of Foot & Ankle Care Very Poor	Cleanliness of Foot & Ankle Care Poor	Cleanliness of Foot & Ankle Care Fair	Cleanliness of Foot & Ankle Care Good	Cleanliness of Foot & Ankle Care Excellent
Concern for your privacy	Concern for your privacy Very Poor	Concern for your privacy Poor	Concern for your privacy Fair	Concern for your privacy Good	Concern for your privacy Excellent

Other (please specify)

7. Would you recommend the physician to others?

Would you recommend the physician to others?

8. Any suggestions to improve doctor/patient relationship?

Any suggestions to improve doctor/patient relationship?

THANK YOU FOR TAKING THE TIME TO ANSWER OUR QUESTIONS!
WE STRIVE TO PROVIDE THE BEST FOR OUR PATIENTS

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Patient SurveyExit this survey

1. Default Section

*1. Date

2. Background Questions:

3. Please rate the following qualities of our receptionists:

4. Please rate your Doctor Visit:

5. Please rate our Scheduling Procedure:

6. Some Final Ratings:

7. Would you recommend the physician to others?

8. Any suggestions to improve doctor/patient relationship?

Patient Survey
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1. Date