1. Default Section

* 1. Patient Information (helpful, but not required):

* 3. Patient Satisfaction:

  Strongly Disagree Disagree Neither agree or disagree Agree Strongly Agree
Was your appointment scheduled in a resonable timeframe?
The office hours were convenient.
The facility was clean.
Office staff was courteous and helpful.
Wait time was reasonable.
I had adequate time with my provider.
I feel comfortable with my treament plan.
I recieved adequate instructions or information on my condition.
I feel confident in my knowledge of and ability to provide self care (ex: diet, exercise, taking medications as prescribed, gluscose testing (if applicabel), etc) for my condition.
I feel comfortable communicating with my doctors office to report changes in my symptoms.

* 4. While in our office, how often did your nurse:

  Never Sometimes Often Frequently Always
Treat you with courtesy and respect?
Listen carefully to you?
Explain things in a way you could understand?
Take time to answer your questions?

* 5. While in our office, how often did the doctor/provider:

  Never Sometimes Often Frequently Always
Treat you with courtesy and respect?
Listen carefully to you?
Explain things in a way you could understand?
Take time to answer your questions?

* 6. Please rate the following:

  Not Involved/Satisfied Indifferent Extremely Involved/Satisfied
How involved are you in the management of your condition?
Overall, how would you rate your last visit

* 7. Have we made any changes that have enhanced your experience with our practice?

* 8. What would make your experience at Mackey Family Practice better?

* 9. Would you recommend this office to your friends or family?

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