Skip to content
Patient Satisfaction Survey
Your Health and Your Interactions with Staff
1.
How would you rate your overall health?
Poor
1 star
Fair
2 stars
Ok
3 stars
Good
4 stars
Great
5 stars
2.
How would you rate your health BEFORE coming to the Community Clinic?
Poor
1 star
Fair
2 stars
Ok
3 stars
Good
4 stars
Great
5 stars
3.
How would you rate your health AFTER coming to the Community Clinic?
Poor
1 star
Fair
2 stars
Ok
3 stars
Good
4 stars
Great
5 stars
4.
The provider (doctor, dentist, nurse practitioner, counselor, etc.) listens to me.
Strongly disagree
1 star
Disagree
2 stars
Somewhat
3 stars
Agree
4 stars
Strongly Agree
5 stars
5.
The provider (doctor, dentist, nurse practitioner, counselor, etc.) takes enough time with me.
Strongly Disagree
1 star
Disagree
2 stars
Somewhat
3 stars
Agree
4 stars
Strongly Agree
5 stars
6.
The provider (doctor, dentist, nurse practitioner, counselor, etc.) explains what I need to know.
Strongly Disagree
1 star
Disagree
2 stars
Somewhat
3 stars
Agree
4 stars
Strongly Agree
5 stars
7.
The provider (doctor, dentist, nurse practitioner, counselor, etc.) gives me good advice and treatment.
Strongly Disagree
1 star
Disagree
2 stars
Somewhat
3 stars
Agree
4 stars
Strongly Agree
5 stars
8.
The nurses and medical assistants are friendly and helpful to me.
Strongly disagree
1 star
Disagree
2 stars
Somewhat
3 stars
Agree
4 stars
Strongly Agree
5 stars
9.
The front office staff members are friendly and they answer my questions effectively.
Strongly Disagree
1 star
Disagree
2 stars
Somewhat
3 stars
Agree
4 stars
Strongly Agree
5 stars
10.
The Community Clinic has addressed my medical, dental, or counseling needs.
Strongly Disagree
1 star
Disagree
2 stars
Somewhat
3 stars
Agree
4 stars
Strongly Agree
5 stars
11.
What do you like best about the Community Clinic?
12.
How has the Community Clinic improved your life?
13.
What are your suggestions for improvement of the Community Clinic?
14.
What services have you received from the clinic? (check all that apply)
Primary Care
Cardiology Clinic
Pulmonology Clinic
Gynecology Clinic
Dental
Vision Assistance
Pharmacy
Lab Work
Nutrition
Cooking Classes
Fitbit Group
Counseling
Patient Advocacy
Diabetic Clinic
Chiropractic
Orthopedic Clinic
Pediatrics
Diabetic Education
Tobacco Cessation
Other (please specify)
Current Progress,
0 of 26 answered
