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Northern Potter Health Center

 

1. Please rank your satisfaction with our services in the following areas:

	Extremely satisfied	Satisfied	Fair	dissatisfied	Extremely dissatisfied
Length of time it took to get an appointment	*Please rank your satisfaction with our services in the following areas: Length of time it took to get an appointment Extremely satisfied	Length of time it took to get an appointment Satisfied	Length of time it took to get an appointment Fair	Length of time it took to get an appointment dissatisfied	Length of time it took to get an appointment Extremely dissatisfied
Length of time spent in office waiting to be seen	Length of time spent in office waiting to be seen Extremely satisfied	Length of time spent in office waiting to be seen Satisfied	Length of time spent in office waiting to be seen Fair	Length of time spent in office waiting to be seen dissatisfied	Length of time spent in office waiting to be seen Extremely dissatisfied
Cleanliness/comfort of office	Cleanliness/comfort of office Extremely satisfied	Cleanliness/comfort of office Satisfied	Cleanliness/comfort of office Fair	Cleanliness/comfort of office dissatisfied	Cleanliness/comfort of office Extremely dissatisfied
Friendliness and helpfulness of front desk staff	Friendliness and helpfulness of front desk staff Extremely satisfied	Friendliness and helpfulness of front desk staff Satisfied	Friendliness and helpfulness of front desk staff Fair	Friendliness and helpfulness of front desk staff dissatisfied	Friendliness and helpfulness of front desk staff Extremely dissatisfied
Friendliness and helpfulness of nursing staff	Friendliness and helpfulness of nursing staff Extremely satisfied	Friendliness and helpfulness of nursing staff Satisfied	Friendliness and helpfulness of nursing staff Fair	Friendliness and helpfulness of nursing staff dissatisfied	Friendliness and helpfulness of nursing staff Extremely dissatisfied
Friendliness and helpfulness of practitioner	Friendliness and helpfulness of practitioner Extremely satisfied	Friendliness and helpfulness of practitioner Satisfied	Friendliness and helpfulness of practitioner Fair	Friendliness and helpfulness of practitioner dissatisfied	Friendliness and helpfulness of practitioner Extremely dissatisfied
Explanation of diagnosis	Explanation of diagnosis Extremely satisfied	Explanation of diagnosis Satisfied	Explanation of diagnosis Fair	Explanation of diagnosis dissatisfied	Explanation of diagnosis Extremely dissatisfied
Explanation of prescribed medications and side effects	Explanation of prescribed medications and side effects Extremely satisfied	Explanation of prescribed medications and side effects Satisfied	Explanation of prescribed medications and side effects Fair	Explanation of prescribed medications and side effects dissatisfied	Explanation of prescribed medications and side effects Extremely dissatisfied
Practice staff concern for your privacy	Practice staff concern for your privacy Extremely satisfied	Practice staff concern for your privacy Satisfied	Practice staff concern for your privacy Fair	Practice staff concern for your privacy dissatisfied	Practice staff concern for your privacy Extremely dissatisfied
Overall satisfaction with the practice	Overall satisfaction with the practice Extremely satisfied	Overall satisfaction with the practice Satisfied	Overall satisfaction with the practice Fair	Overall satisfaction with the practice dissatisfied	Overall satisfaction with the practice Extremely dissatisfied

2. Please provide additional information relating to experience with the physician office:

	Yes	No
Would you reccomend this practice to family or friends?	*Please provide additional information relating to experience with the physician office: Would you reccomend this practice to family or friends? Yes	Would you reccomend this practice to family or friends? No
Was this your first visit to the office?	Was this your first visit to the office? Yes	Was this your first visit to the office? No

3. What date was your appointment?

What date was your appointment?

4. How did you hear about our practice?

How did you hear about our practice?   Referred by physician Friend or family member Phone Directory	Internet Newspaper Flyer	Direct mail
Other (list)

5. Which provider did you see at this visit?

Which provider did you see at this visit?

6. If you needed tests, did you use CCMH services

YesNo

If you needed tests, did you use CCMH services

7. Did you require additional tests (laboratory, radiology, cardiology, etc)

YesNo

Did you require additional tests (laboratory, radiology, cardiology, etc)

8. How old are you?

0-1819-2930-3940-4950-5960-6566+

How old are you?

9. Were there any staff members who were especially helpful that you would like to mention?

Were there any staff members who were especially helpful that you would like to mention?

10. What suggestions do you have for how we can improve our services?

What suggestions do you have for how we can improve our services?

11. If you would like someone to contact you regarding the experience you had at the physician office, please complete the following:

If you would like someone to contact you regarding the experience you had at the physician office, please complete the following:   Name
Phone Number
Email