Dear Patient:  As part of our ongoing efforts to provide the highest quality service to our patients we are very interested in receiving your feedback about the care you received from our office.  Please take a few minutes to complete this survey and return it to us.  Your response is very important to us.  Your answers will be kept confidential and all results will be aggregated and utilized to improve patient care.  Thank you in advance for your help.

Ease of making your appointment by telephone

Question Title

* 1. Ease of making your appointment by telephone

Ability to get a appointment as quickly as you wanted it

Question Title

* 2. Ability to get a appointment as quickly as you wanted it

Ability to be seen on the day and time that works best for you

Question Title

* 3. Ability to be seen on the day and time that works best for you

The time that you spent in the waiting room and exam room before seeing your doctor

Question Title

* 4. The time that you spent in the waiting room and exam room before seeing your doctor

The friendliness of the front desk staff

Question Title

* 5. The friendliness of the front desk staff

The caring and concern of the nurses/medical assistants

Question Title

* 6. The caring and concern of the nurses/medical assistants

The speed with which your telephone calls are answered

Question Title

* 7. The speed with which your telephone calls are answered

Your ability to get help or advice during office hours by telephone

Question Title

* 8. Your ability to get help or advice during office hours by telephone

The way your doctor listened to your concerns and showed understanding of your health condition

Question Title

* 9. The way your doctor listened to your concerns and showed understanding of your health condition

Your doctor’s explanation of things in a way you could understand

Question Title

* 10. Your doctor’s explanation of things in a way you could understand

Ease of understanding instructions regarding your medication and follow-up care

Question Title

* 11. Ease of understanding instructions regarding your medication and follow-up care

The availability of your health information, such as test results

Question Title

* 12. The availability of your health information, such as test results

Your doctor’s communication with other providers involved in your care

Question Title

* 13. Your doctor’s communication with other providers involved in your care

Your doctor’s efforts to involve you in planning your own care

Question Title

* 14. Your doctor’s efforts to involve you in planning your own care

Your doctor’s use of a patient centered approach to your care

Question Title

* 15. Your doctor’s use of a patient centered approach to your care

The quality and ease of use of the self-management tools given to you by the practice

Question Title

* 16. The quality and ease of use of the self-management tools given to you by the practice

How satisfied are you with our practice overall

Question Title

* 17. How satisfied are you with our practice overall

How likely are you to recommend our practice to your friends and family

Question Title

* 18. How likely are you to recommend our practice to your friends and family

Please let us know the reasons you would or would not recommend our practice to others.

Question Title

* 19. Please let us know the reasons you would or would not recommend our practice to others.

Please let us know if there is anything we can do to improve our services to you.

Question Title

* 20. Please let us know if there is anything we can do to improve our services to you.

Gender:

Question Title

* 21. Gender:

Primary language

Question Title

* 22. Primary language

Do you have health insurance?

Question Title

* 23. Do you have health insurance?

Insurance Type:

Question Title

* 24. Insurance Type:

Date of Service:

Question Title

* 25. Date of Service:

Provider Seen:

Question Title

* 26. Provider Seen:

T