1. Patient Survey

* 1. What was the date of your visit?

* 2. Was your appointment in the morning, afternoon, or evening?

* 3. Are you a new patient to our clinic or a returning patient?

* 4. My appointment was with:

* 5. My appointment was at the:

* 6. What factors influenced your initial choice of our office?

* 7. The amount of time the doctor spent with me was adequate for my needs.

* 8. The physician treated me with dignity, respect and patience.

* 9. Did the doctor fully answer your questions?

* 10. Did you feel the doctor was interested in you and your medical problem?

* 11. How long did you wait to be seen by the doctor AFTER you checked in for your appointment?

* 12. The physician gave me time to ask questions?