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SCHC Patient Satisfaction Survey
*
1.
Please rate your overall experience today
(Required.)
1 Not satisfied at all
1 star
2
2 stars
3
3 stars
4
4 stars
5
5 stars
6
6 stars
7
7 stars
8
8 stars
9
9 stars
10 Extremely satisfied
10 stars
Comments/Details:
*
2.
Which provider did you see today?
(Required.)
Gina Catley, LCSW
Ed Gonzalez, FNP
Dr. Becki Schellinger
Andrea Helmer, ANP
Jeanette Nienaber, PA-C
Christie Griffin, ANP
Clinic Nurse
Chrissy Forgione, LCSW
Sam Johnson, LCSW
I don't know
Dr. Harsha Gowtham
Other (please specify)
3.
When making your appointment, were you given a chance to see your primary care provider?
Yes
No
N/A
I don't have a primary care provider
Comments/Details:
4.
How satisfied were you with the
appointment time
you were able to get?
1 Not satisfied at all
1 star
2
2 stars
3
3 stars
4
4 stars
5
5 stars
6
6 stars
7
7 stars
8
8 stars
9
9 stars
10 Extremely satisfied
10 stars
Comments/details:
5.
How satisfied were you with the following?
1 Not satisfied at all
2
3
4
5 Extremely satisfied
N/A
Front desk staff knowledge & friendliness
1 Not satisfied at all
2
3
4
5 Extremely satisfied
N/A
Nursing staff knowledge & friendliness
1 Not satisfied at all
2
3
4
5 Extremely satisfied
N/A
Provider knowledge & friendliness
1 Not satisfied at all
2
3
4
5 Extremely satisfied
N/A
Cleanliness of the clinic
1 Not satisfied at all
2
3
4
5 Extremely satisfied
N/A
Comments/details:
6.
How would you rate the length of time you spent waiting during today's visit?
Too short
About the right length
Too long
Comments/details:
7.
How satisfied were you with the amount of time your provider spent with you addressing your needs?
Too short
About the right length
Too long
Comments/details:
8.
Is there anyone on our team you would like to recognize or thank for how they cared for you today?
No
Yes
9.
Are any of these keeping you from reaching your physical and mental wellness goals?
None
Cost / too expensive
I don't have insurance/enough coverage
Transportation
Access to nutritious foods
Access to clean water and utilities (e.g., electricity, sanitation, heating)
Lack of family and/or social support
Other (please specify)
10.
Is there anything we could have done to improve your visit today?
No
Yes
Current Progress,
0 of 10 answered
