Patient Survey

Provider Information

Please tell us which provider you are evaluating. If you have seen more than one provider, please complete a separate survey for each one.

Question Title

* Quarter

Q1 January 2024-March 2024

Q2 April 2024-June 2024

Question Title

* Which Physician are you evaluating?

Nicklaus Bradley, M.D.

Danielle Brown, FNP

Branislav D. Behan, MD, FRCS(C)

Laura Parks, DO

Other (please specify)

Question Title

* Provider status

	No	Yes
Do you consider them your primary provider/specialist?	Do you consider them your primary provider/specialist? No	Do you consider them your primary provider/specialist? Yes
Do you have a different primary provider and saw the provider above for a special reason?	Do you have a different primary provider and saw the provider above for a special reason? No	Do you have a different primary provider and saw the provider above for a special reason? Yes
Are you considering changing providers?	Are you considering changing providers? No	Are you considering changing providers? Yes
Have you already changed or decided to change providers?	Have you already changed or decided to change providers? No	Have you already changed or decided to change providers? Yes

Question Title

* When was your last visit to this provider?

Past 30 days

1-6 months

6 mo-1 year

1-2 years

Other (please specify)

Question Title

* How satisfied are you with the following?

	5-Very Satisfied	4-Satisfied	3-Average Satisfaction	2-Unsatisfied	1-Very Unsatisfied
1. Provider's caring attitude	1. Provider's caring attitude 5-Very Satisfied	1. Provider's caring attitude 4-Satisfied	1. Provider's caring attitude 3-Average Satisfaction	1. Provider's caring attitude 2-Unsatisfied	1. Provider's caring attitude 1-Very Unsatisfied
2. Completeness of your examination or checkup	2. Completeness of your examination or checkup 5-Very Satisfied	2. Completeness of your examination or checkup 4-Satisfied	2. Completeness of your examination or checkup 3-Average Satisfaction	2. Completeness of your examination or checkup 2-Unsatisfied	2. Completeness of your examination or checkup 1-Very Unsatisfied
3. Amount of time provider spent with you	3. Amount of time provider spent with you 5-Very Satisfied	3. Amount of time provider spent with you 4-Satisfied	3. Amount of time provider spent with you 3-Average Satisfaction	3. Amount of time provider spent with you 2-Unsatisfied	3. Amount of time provider spent with you 1-Very Unsatisfied
4. How the provider answered your questions	4. How the provider answered your questions 5-Very Satisfied	4. How the provider answered your questions 4-Satisfied	4. How the provider answered your questions 3-Average Satisfaction	4. How the provider answered your questions 2-Unsatisfied	4. How the provider answered your questions 1-Very Unsatisfied
5. Instructions on taking care of your illness or health condition	5. Instructions on taking care of your illness or health condition 5-Very Satisfied	5. Instructions on taking care of your illness or health condition 4-Satisfied	5. Instructions on taking care of your illness or health condition 3-Average Satisfaction	5. Instructions on taking care of your illness or health condition 2-Unsatisfied	5. Instructions on taking care of your illness or health condition 1-Very Unsatisfied
6. How the provider included you in decisions about your care and treatment	6. How the provider included you in decisions about your care and treatment 5-Very Satisfied	6. How the provider included you in decisions about your care and treatment 4-Satisfied	6. How the provider included you in decisions about your care and treatment 3-Average Satisfaction	6. How the provider included you in decisions about your care and treatment 2-Unsatisfied	6. How the provider included you in decisions about your care and treatment 1-Very Unsatisfied
7. The timing and how you received your test results (leave blank if does not apply)	7. The timing and how you received your test results (leave blank if does not apply) 5-Very Satisfied	7. The timing and how you received your test results (leave blank if does not apply) 4-Satisfied	7. The timing and how you received your test results (leave blank if does not apply) 3-Average Satisfaction	7. The timing and how you received your test results (leave blank if does not apply) 2-Unsatisfied	7. The timing and how you received your test results (leave blank if does not apply) 1-Very Unsatisfied
8. Provider follow up on your problems or concerns (leave blank if does not apply)	8. Provider follow up on your problems or concerns (leave blank if does not apply) 5-Very Satisfied	8. Provider follow up on your problems or concerns (leave blank if does not apply) 4-Satisfied	8. Provider follow up on your problems or concerns (leave blank if does not apply) 3-Average Satisfaction	8. Provider follow up on your problems or concerns (leave blank if does not apply) 2-Unsatisfied	8. Provider follow up on your problems or concerns (leave blank if does not apply) 1-Very Unsatisfied
9. How well your treatment solved your problem or improved your health	9. How well your treatment solved your problem or improved your health 5-Very Satisfied	9. How well your treatment solved your problem or improved your health 4-Satisfied	9. How well your treatment solved your problem or improved your health 3-Average Satisfaction	9. How well your treatment solved your problem or improved your health 2-Unsatisfied	9. How well your treatment solved your problem or improved your health 1-Very Unsatisfied
10. The service you received from the medical assistant or nurse	10. The service you received from the medical assistant or nurse 5-Very Satisfied	10. The service you received from the medical assistant or nurse 4-Satisfied	10. The service you received from the medical assistant or nurse 3-Average Satisfaction	10. The service you received from the medical assistant or nurse 2-Unsatisfied	10. The service you received from the medical assistant or nurse 1-Very Unsatisfied
11. The service you received from office staff	11. The service you received from office staff 5-Very Satisfied	11. The service you received from office staff 4-Satisfied	11. The service you received from office staff 3-Average Satisfaction	11. The service you received from office staff 2-Unsatisfied	11. The service you received from office staff 1-Very Unsatisfied
12. Phones efficiently answered when calling for appointment (not having to leave message during office hours)	12. Phones efficiently answered when calling for appointment (not having to leave message during office hours) 5-Very Satisfied	12. Phones efficiently answered when calling for appointment (not having to leave message during office hours) 4-Satisfied	12. Phones efficiently answered when calling for appointment (not having to leave message during office hours) 3-Average Satisfaction	12. Phones efficiently answered when calling for appointment (not having to leave message during office hours) 2-Unsatisfied	12. Phones efficiently answered when calling for appointment (not having to leave message during office hours) 1-Very Unsatisfied
13. Your appointment time or waiting time	13. Your appointment time or waiting time 5-Very Satisfied	13. Your appointment time or waiting time 4-Satisfied	13. Your appointment time or waiting time 3-Average Satisfaction	13. Your appointment time or waiting time 2-Unsatisfied	13. Your appointment time or waiting time 1-Very Unsatisfied

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