2020 Multidisciplinary Clinic Satisfaction Survey

Question Title

* 1. Please select which applies to you:

Attended clinic in person.

Attended clinic via telehealth/virtual.

Question Title

* 2. Please select which applies to you:

Attended clinic one time.

Attended clinic more than one time.

Question Title

* 3. Please confirm the Clinic you attend.

Mayo Clinic in Florida ALS Center of Excellence

University of Miami Kessenich Family ALS Center of Excellence

University of South Florida ALS Center of Excellence

UF Health Jacksonville ALS Center of Excellence

Phil Smith Neuroscience Institute at Holy Cross ALS Center of Excellence

UF Health Gainesville ALS Clinic

Orlando Health ALS Clinic

Lee Health ALS Recognized Treatment Center

Other (please specify)

Question Title

* 4. Please rate your level of satisfaction with the following experiences during your clinic visits within the last year.

	very satisfied	satisfied	neutral	dissatisfied	very dissatisfied
The process of scheduling clinic visits.	The process of scheduling clinic visits. very satisfied	The process of scheduling clinic visits. satisfied	The process of scheduling clinic visits. neutral	The process of scheduling clinic visits. dissatisfied	The process of scheduling clinic visits. very dissatisfied
Response to concerns/questions made during your visit.	Response to concerns/questions made during your visit. very satisfied	Response to concerns/questions made during your visit. satisfied	Response to concerns/questions made during your visit. neutral	Response to concerns/questions made during your visit. dissatisfied	Response to concerns/questions made during your visit. very dissatisfied
The courtesy and respect shown to you and your family by the staff.	The courtesy and respect shown to you and your family by the staff. very satisfied	The courtesy and respect shown to you and your family by the staff. satisfied	The courtesy and respect shown to you and your family by the staff. neutral	The courtesy and respect shown to you and your family by the staff. dissatisfied	The courtesy and respect shown to you and your family by the staff. very dissatisfied
Follow up after clinic visit (e.g. prescriptions, equipment orders, resources).	Follow up after clinic visit (e.g. prescriptions, equipment orders, resources). very satisfied	Follow up after clinic visit (e.g. prescriptions, equipment orders, resources). satisfied	Follow up after clinic visit (e.g. prescriptions, equipment orders, resources). neutral	Follow up after clinic visit (e.g. prescriptions, equipment orders, resources). dissatisfied	Follow up after clinic visit (e.g. prescriptions, equipment orders, resources). very dissatisfied
Clinic staff worked together to care for you.	Clinic staff worked together to care for you. very satisfied	Clinic staff worked together to care for you. satisfied	Clinic staff worked together to care for you. neutral	Clinic staff worked together to care for you. dissatisfied	Clinic staff worked together to care for you. very dissatisfied
Your overall satisfaction with your clinic visits.	Your overall satisfaction with your clinic visits. very satisfied	Your overall satisfaction with your clinic visits. satisfied	Your overall satisfaction with your clinic visits. neutral	Your overall satisfaction with your clinic visits. dissatisfied	Your overall satisfaction with your clinic visits. very dissatisfied

Question Title

* 5. Please mark your level of agreement with the following statements about your clinic visits.

	strongly agree	agree	neutral	disagree	strongly disagree
The staff was knowledgeable about my condition and status during the visit.	The staff was knowledgeable about my condition and status during the visit. strongly agree	The staff was knowledgeable about my condition and status during the visit. agree	The staff was knowledgeable about my condition and status during the visit. neutral	The staff was knowledgeable about my condition and status during the visit. disagree	The staff was knowledgeable about my condition and status during the visit. strongly disagree
The expectations I had about attending clinic were met.	The expectations I had about attending clinic were met. strongly agree	The expectations I had about attending clinic were met. agree	The expectations I had about attending clinic were met. neutral	The expectations I had about attending clinic were met. disagree	The expectations I had about attending clinic were met. strongly disagree

2020 Multidisciplinary Clinic Satisfaction Survey

Satisfaction Survey

Question Title

* 1. Please select which applies to you:

Question Title

* 2. Please select which applies to you:

Question Title

* 3. Please confirm the Clinic you attend.

Question Title

* 4. Please rate your level of satisfaction with the following experiences during your clinic visits within the last year.

Question Title

* 5. Please mark your level of agreement with the following statements about your clinic visits.

Question Title

* 6. What do you like about your clinic visit experience?

Question Title

* 7. Please provide comments/suggestions to help improve your clinic visit experience.

Question Title

* 8. Please provide your name/email (optional):