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ANONYMOUS Survey about your Doctor

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* 1. Your doctor's initials should be placed here by the nurse or you.

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* 2. Did your doctor introduce him/herself to you?

Yes

No

Not Sure

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* 3. Did your doctor seem to care about you as a person?

Yes

No

Not sure

Other (please specify)

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* 4. Did your doctor spend enough time with you?

Yes

No

Not Sure

Other (please specify)

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* 5. Did your doctor answer your questions?

Yes

No

Not Sure

Other (please specify)

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* 6. Do you trust this doctor to make medical decisions that are in your best interests?

Yes

No

Not Sure

Other (please specify)

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* 7. Is there anything else that your doctor could have done to improve your visit today?