Patient Satisfaction Feedback Form

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* 1. Who is completing this form?

Yourself

Parent

Caregiver

Other (please specify)

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* 2. Gender

Male

Female

Other (please specify)

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* 3. Age Bracket

Under 18

18-24

25-34

35-44

45-54

55-64

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* 4. Indigenous status

Aboriginal & Torres Strait Islander

Aboriginal

Torres Strait Islander

Other (please specify)

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* 5. A. YOUR APPOINTMENT:

	Poor	Fair	Good	Very Good	Excellent	N/A
Ease of seeing an Aboriginal Health Practitioner or Nurse	Ease of seeing an Aboriginal Health Practitioner or Nurse Poor	Ease of seeing an Aboriginal Health Practitioner or Nurse Fair	Ease of seeing an Aboriginal Health Practitioner or Nurse Good	Ease of seeing an Aboriginal Health Practitioner or Nurse Very Good	Ease of seeing an Aboriginal Health Practitioner or Nurse Excellent	Ease of seeing an Aboriginal Health Practitioner or Nurse N/A
Seeing a doctor within a reasonable amount of time	Seeing a doctor within a reasonable amount of time Poor	Seeing a doctor within a reasonable amount of time Fair	Seeing a doctor within a reasonable amount of time Good	Seeing a doctor within a reasonable amount of time Very Good	Seeing a doctor within a reasonable amount of time Excellent	Seeing a doctor within a reasonable amount of time N/A
Getting care for illness/injury as soon as you wanted it	Getting care for illness/injury as soon as you wanted it Poor	Getting care for illness/injury as soon as you wanted it Fair	Getting care for illness/injury as soon as you wanted it Good	Getting care for illness/injury as soon as you wanted it Very Good	Getting care for illness/injury as soon as you wanted it Excellent	Getting care for illness/injury as soon as you wanted it N/A
The efficiency of the check-in process	The efficiency of the check-in process Poor	The efficiency of the check-in process Fair	The efficiency of the check-in process Good	The efficiency of the check-in process Very Good	The efficiency of the check-in process Excellent	The efficiency of the check-in process N/A
Waiting time in the reception area	Waiting time in the reception area Poor	Waiting time in the reception area Fair	Waiting time in the reception area Good	Waiting time in the reception area Very Good	Waiting time in the reception area Excellent	Waiting time in the reception area N/A
Waiting time in the exam room	Waiting time in the exam room Poor	Waiting time in the exam room Fair	Waiting time in the exam room Good	Waiting time in the exam room Very Good	Waiting time in the exam room Excellent	Waiting time in the exam room N/A
Keeping you informed if there was going to be a delay	Keeping you informed if there was going to be a delay Poor	Keeping you informed if there was going to be a delay Fair	Keeping you informed if there was going to be a delay Good	Keeping you informed if there was going to be a delay Very Good	Keeping you informed if there was going to be a delay Excellent	Keeping you informed if there was going to be a delay N/A
Ease of getting a referral when you needed one	Ease of getting a referral when you needed one Poor	Ease of getting a referral when you needed one Fair	Ease of getting a referral when you needed one Good	Ease of getting a referral when you needed one Very Good	Ease of getting a referral when you needed one Excellent	Ease of getting a referral when you needed one N/A

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* 6. B. OUR STAFF:

	Poor	Fair	Good	Very Good	Excellent	N/A
The courtesy of the person who took your call	The courtesy of the person who took your call Poor	The courtesy of the person who took your call Fair	The courtesy of the person who took your call Good	The courtesy of the person who took your call Very Good	The courtesy of the person who took your call Excellent	The courtesy of the person who took your call N/A
The friendliness and courtesy of the receptionist	The friendliness and courtesy of the receptionist Poor	The friendliness and courtesy of the receptionist Fair	The friendliness and courtesy of the receptionist Good	The friendliness and courtesy of the receptionist Very Good	The friendliness and courtesy of the receptionist Excellent	The friendliness and courtesy of the receptionist N/A
The caring concern of our Aboriginal Health Practitioners/Nurses	The caring concern of our Aboriginal Health Practitioners/Nurses Poor	The caring concern of our Aboriginal Health Practitioners/Nurses Fair	The caring concern of our Aboriginal Health Practitioners/Nurses Good	The caring concern of our Aboriginal Health Practitioners/Nurses Very Good	The caring concern of our Aboriginal Health Practitioners/Nurses Excellent	The caring concern of our Aboriginal Health Practitioners/Nurses N/A

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* 7. C. OUR COMMUNICATION WITH YOU:

	Poor	Fair	Good	Very Good	Excellent	N/A
Your phone calls answered promptly	Your phone calls answered promptly Poor	Your phone calls answered promptly Fair	Your phone calls answered promptly Good	Your phone calls answered promptly Very Good	Your phone calls answered promptly Excellent	Your phone calls answered promptly N/A
Getting advice or help when needed during office hours	Getting advice or help when needed during office hours Poor	Getting advice or help when needed during office hours Fair	Getting advice or help when needed during office hours Good	Getting advice or help when needed during office hours Very Good	Getting advice or help when needed during office hours Excellent	Getting advice or help when needed during office hours N/A
Explanation of your health issue	Explanation of your health issue Poor	Explanation of your health issue Fair	Explanation of your health issue Good	Explanation of your health issue Very Good	Explanation of your health issue Excellent	Explanation of your health issue N/A
Your test results reported in a reasonable amount of time	Your test results reported in a reasonable amount of time Poor	Your test results reported in a reasonable amount of time Fair	Your test results reported in a reasonable amount of time Good	Your test results reported in a reasonable amount of time Very Good	Your test results reported in a reasonable amount of time Excellent	Your test results reported in a reasonable amount of time N/A
Effectiveness of our health information materials	Effectiveness of our health information materials Poor	Effectiveness of our health information materials Fair	Effectiveness of our health information materials Good	Effectiveness of our health information materials Very Good	Effectiveness of our health information materials Excellent	Effectiveness of our health information materials N/A
Our ability to return your calls in a timely manner	Our ability to return your calls in a timely manner Poor	Our ability to return your calls in a timely manner Fair	Our ability to return your calls in a timely manner Good	Our ability to return your calls in a timely manner Very Good	Our ability to return your calls in a timely manner Excellent	Our ability to return your calls in a timely manner N/A

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* 8. D. YOUR VISIT WITH THE DOCTOR:

	Poor	Fair	Good	Very Good	Excellent	N/A
Willingness to listen carefully to you	Willingness to listen carefully to you Poor	Willingness to listen carefully to you Fair	Willingness to listen carefully to you Good	Willingness to listen carefully to you Very Good	Willingness to listen carefully to you Excellent	Willingness to listen carefully to you N/A
Taking time to answer your questions	Taking time to answer your questions Poor	Taking time to answer your questions Fair	Taking time to answer your questions Good	Taking time to answer your questions Very Good	Taking time to answer your questions Excellent	Taking time to answer your questions N/A
Amount of time spent with you	Amount of time spent with you Poor	Amount of time spent with you Fair	Amount of time spent with you Good	Amount of time spent with you Very Good	Amount of time spent with you Excellent	Amount of time spent with you N/A
Explaining things in a way you could understand	Explaining things in a way you could understand Poor	Explaining things in a way you could understand Fair	Explaining things in a way you could understand Good	Explaining things in a way you could understand Very Good	Explaining things in a way you could understand Excellent	Explaining things in a way you could understand N/A
Instructions regarding medication/follow-up care	Instructions regarding medication/follow-up care Poor	Instructions regarding medication/follow-up care Fair	Instructions regarding medication/follow-up care Good	Instructions regarding medication/follow-up care Very Good	Instructions regarding medication/follow-up care Excellent	Instructions regarding medication/follow-up care N/A
The thoroughness of the examination	The thoroughness of the examination Poor	The thoroughness of the examination Fair	The thoroughness of the examination Good	The thoroughness of the examination Very Good	The thoroughness of the examination Excellent	The thoroughness of the examination N/A
Advice given to you on ways to stay healthy	Advice given to you on ways to stay healthy Poor	Advice given to you on ways to stay healthy Fair	Advice given to you on ways to stay healthy Good	Advice given to you on ways to stay healthy Very Good	Advice given to you on ways to stay healthy Excellent	Advice given to you on ways to stay healthy N/A

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* 9. E. OUR FACILITY:

	Poor	Fair	Good	Very Good	Excellent	N/A
Hours of operation convenient for you	Hours of operation convenient for you Poor	Hours of operation convenient for you Fair	Hours of operation convenient for you Good	Hours of operation convenient for you Very Good	Hours of operation convenient for you Excellent	Hours of operation convenient for you N/A
Overall comfort	Overall comfort Poor	Overall comfort Fair	Overall comfort Good	Overall comfort Very Good	Overall comfort Excellent	Overall comfort N/A
Adequate parking	Adequate parking Poor	Adequate parking Fair	Adequate parking Good	Adequate parking Very Good	Adequate parking Excellent	Adequate parking N/A
Signage and directions easy to follow	Signage and directions easy to follow Poor	Signage and directions easy to follow Fair	Signage and directions easy to follow Good	Signage and directions easy to follow Very Good	Signage and directions easy to follow Excellent	Signage and directions easy to follow N/A

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* 10. YOUR OVERALL SATISFACTION WITH:

	Poor	Fair	Good	Very Good	Excellent	N/A
Our practice	Our practice Poor	Our practice Fair	Our practice Good	Our practice Very Good	Our practice Excellent	Our practice N/A
The quality of your medical care	The quality of your medical care Poor	The quality of your medical care Fair	The quality of your medical care Good	The quality of your medical care Very Good	The quality of your medical care Excellent	The quality of your medical care N/A
Overall rating of care from our staff	Overall rating of care from our staff Poor	Overall rating of care from our staff Fair	Overall rating of care from our staff Good	Overall rating of care from our staff Very Good	Overall rating of care from our staff Excellent	Overall rating of care from our staff N/A