At Northwest Asthma & Allergy Center, we want to provide the best health care possible. To make this happen, we would appreciate your feedback about what we are doing right and what we could do better. Please take a few minutes to share your clinic experience with us. Your responses are confidential. A space is provided for you to also comment on specific issues (good or bad). We thank you in advance for your time and candid thoughts.

Date of visit: __________________ Physician: _______________

Using the scale below, please rate the services you received from our practice in the following areas.

1=Poor, 2=Fair, 3=Satisfactory, 4=Good, 5=Excellent

* 1. Ease of scheduling your appointment?

* 2. Courtesy of staff assisting you on the phone?

  1 2 3 4 5
2

* 3. Ease of the check-in process when you arrived for your appointment

  1 2 3 4 5
3

* 4. How would you rate the wait time in the office to see the physician

  1 2 3 4 5
4

* 5. How well did the physician answer your questions?

  1 2 3 4 5
5

* 6. Discussion of your care plan with your physician

  1 2 3 4 5
6

* 7. Explanation of your test results

  1 2 3 4 5 N/A
7

* 8. Courtesy of the nurse or assistant helping you during your visit

  1 2 3 4 5
8

* 9. Overall rating of care received during your visit

  1 2 3 4 5
9

* 10. How many minutes did you wait after your scheduled appointment time before you were checked into an exam room?

* 11. How many minutes did you wait in your exam room before a provider saw you?

* 12. Would you recommend our providers to your family and friends?

* 13. Any additional feedback?

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