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* 1. Overall, how satisfied or dissatisfied were you with your last visit to our office?

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* 2. How easy or difficult was it to schedule your appointment at a time that was convenient for you?

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* 3. How convenient was the appointment time you were able to get?

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* 4. In your opinion, how convenient is the location of our office?

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* 5. Overall, how would you rate the service you received from the staff at our office?

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* 6. How comfortable was the lobby and waiting area?

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* 7. Did your appointment with your provider start early, late or on time?

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* 8. Overall, how would you rate the care you received from your provider?

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* 9. How much do you trust your provider to make medical decisions that are in your best interests?

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* 10. How well did your provider listen to your needs?

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* 11. How well did your provider answer your questions?

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* 12. How well did your provider explain your treatment options?

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* 13. How well did your provider explain your follow-up care?

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* 14. How satisfied or dissatisfied were you with the amount of time your provider spent with you addressing your needs?

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* 15. My visit cost/nominal fee was reasonable.

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* 16. How likely is it that you would recommend your provider to a friend or colleague?

Not at all likely
Extremely likely

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* 17. What is your clinic location?

T