Patient Satisfaction Survey
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1. Patient Satisfaction Survey

Please fill out the following patient satisfaction survey.

1. How did you hear about us?

How did you hear about us?

2. Which physician did you see in the clinic?

Which physician did you see in the clinic?

3. Ease of getting care:

	5 - Excellent	4 - Good	3 - Average	2 - Below Average	1 - Not Acceptable
Ability to get in and be seen	*Ease of getting care: Ability to get in and be seen 5 - Excellent	Ability to get in and be seen 4 - Good	Ability to get in and be seen 3 - Average	Ability to get in and be seen 2 - Below Average	Ability to get in and be seen 1 - Not Acceptable
Convenience of center's location	Convenience of center's location 5 - Excellent	Convenience of center's location 4 - Good	Convenience of center's location 3 - Average	Convenience of center's location 2 - Below Average	Convenience of center's location 1 - Not Acceptable
Prompt return on calls	Prompt return on calls 5 - Excellent	Prompt return on calls 4 - Good	Prompt return on calls 3 - Average	Prompt return on calls 2 - Below Average	Prompt return on calls 1 - Not Acceptable

4. Waiting:

	5 - Excellent	4 - Good	3 - Average	2 - Below Average	1 - Not Acceptable
Time in waiting room	*Waiting: Time in waiting room 5 - Excellent	Time in waiting room 4 - Good	Time in waiting room 3 - Average	Time in waiting room 2 - Below Average	Time in waiting room 1 - Not Acceptable
Time in exam room	Time in exam room 5 - Excellent	Time in exam room 4 - Good	Time in exam room 3 - Average	Time in exam room 2 - Below Average	Time in exam room 1 - Not Acceptable
Waiting for tests to be performed	Waiting for tests to be performed 5 - Excellent	Waiting for tests to be performed 4 - Good	Waiting for tests to be performed 3 - Average	Waiting for tests to be performed 2 - Below Average	Waiting for tests to be performed 1 - Not Acceptable
Waiting for test results	Waiting for test results 5 - Excellent	Waiting for test results 4 - Good	Waiting for test results 3 - Average	Waiting for test results 2 - Below Average	Waiting for test results 1 - Not Acceptable

5. Physician

	5 - Excellent	4 - Good	3 - Average	2 - Below Average	1 - Not Acceptable
Listens to you	*Physician Listens to you 5 - Excellent	Listens to you 4 - Good	Listens to you 3 - Average	Listens to you 2 - Below Average	Listens to you 1 - Not Acceptable
Explains what you want to know	Explains what you want to know 5 - Excellent	Explains what you want to know 4 - Good	Explains what you want to know 3 - Average	Explains what you want to know 2 - Below Average	Explains what you want to know 1 - Not Acceptable
Gives you good advice and treatment	Gives you good advice and treatment 5 - Excellent	Gives you good advice and treatment 4 - Good	Gives you good advice and treatment 3 - Average	Gives you good advice and treatment 2 - Below Average	Gives you good advice and treatment 1 - Not Acceptable

6. Nurses and Medical Assistants

	5 - Excellent	4 - Good	3 - Average	2 - Below Average	1 - Not Acceptable
Friendly and helpful to you	*Nurses and Medical Assistants Friendly and helpful to you 5 - Excellent	Friendly and helpful to you 4 - Good	Friendly and helpful to you 3 - Average	Friendly and helpful to you 2 - Below Average	Friendly and helpful to you 1 - Not Acceptable
Answers your questions	Answers your questions 5 - Excellent	Answers your questions 4 - Good	Answers your questions 3 - Average	Answers your questions 2 - Below Average	Answers your questions 1 - Not Acceptable

7. All Others

	5 - Excellent	4 - Good	3 - Average	2 - Below Average	1 - Not Acceptable
Friendly and helpful to you	*All Others Friendly and helpful to you 5 - Excellent	Friendly and helpful to you 4 - Good	Friendly and helpful to you 3 - Average	Friendly and helpful to you 2 - Below Average	Friendly and helpful to you 1 - Not Acceptable
Answers your questions	Answers your questions 5 - Excellent	Answers your questions 4 - Good	Answers your questions 3 - Average	Answers your questions 2 - Below Average	Answers your questions 1 - Not Acceptable

8. Facility

	5 - Excellent	4 - Good	3 - Average	2 - Below Average	1 - Not Acceptable
Neat and clean building	*Facility Neat and clean building 5 - Excellent	Neat and clean building 4 - Good	Neat and clean building 3 - Average	Neat and clean building 2 - Below Average	Neat and clean building 1 - Not Acceptable
Ease of finding where to go	Ease of finding where to go 5 - Excellent	Ease of finding where to go 4 - Good	Ease of finding where to go 3 - Average	Ease of finding where to go 2 - Below Average	Ease of finding where to go 1 - Not Acceptable
Comfort and Safety while waiting	Comfort and Safety while waiting 5 - Excellent	Comfort and Safety while waiting 4 - Good	Comfort and Safety while waiting 3 - Average	Comfort and Safety while waiting 2 - Below Average	Comfort and Safety while waiting 1 - Not Acceptable

9. The likelihood of referring your friends and relatives to us

The likelihood of referring your friends and relatives to us 5 - Excellent

4 - Good

3 - Average

2 - Below Average

1 - Not Acceptable

10. What do you like best about our clinic?

What do you like best about our clinic?

11. What do you like least about our clinic?

What do you like least about our clinic?

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