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* 1. Which provider did you most recently see?

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* 2. Rate the ease of scheduling your appointment and convenience of the scheduled time.

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* 3. Rate the courtesy and professionalism of nursing staff.

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* 4. Rate the wait time to see your physician.

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* 5. Provider explained things in a way that was easy to understand.

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* 6. Provider showed respect for what I/the patient had to say.

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* 7. Provider gave clear follow-up instructions (on medications, referrals, later appointments, etc.).

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* 8. Rate the friendliness and courtesy of our staff.

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* 9. Rate your overall experience with us.

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* 10. Please tell us what we can do to improve (bedside manner, hours of availability, communication, etc).

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