Provider Information

Please tell us which provider you are evaluating. If you have seen more than one provider, please complete a separate survey for each one.

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* Quarter

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* Which Physician are you evaluating?

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* Provider status

  No Yes
Do you consider them your primary provider/specialist?
Do you have a different primary provider and saw the provider above for a special reason?
Are you considering changing providers?
Have you already changed or decided to change providers?

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* When was your last visit to this provider?

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* How satisfied are you with the following?

  Very Satisfied Satisfied Average Satisfaction Unsatisfied Very Unsatisfied
1. Provider's caring attitude
2. Completeness of your examination or checkup
3. Amount of time provider spent with you
4. How the provider answered your questions
5. Instructions on taking care of your illness or health condition
6. How the provider included you in decisions about your care and treatment
7. The timing and how you received your test results (leave blank if does not apply)
8. Physician follow up on your problems or concerns (leave blank if does not apply)
9. How well your treatment solved your problem or improved your health
10. The service you received from the medical assistant or nurse
11. The service you received from office staff
12. Phones efficiently answered when calling for appointment (not having to leave message during office hours)
13. Your appointment time or waiting time

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* 14. Did you see the health consultant to discuss how to manage your health?

T