Healdsburg Hospital Patient Feedback Form Survey

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* 1. Where was your last visit:

Emergency Room

Physician’s Office

Surgery

Lab

Wound Care

Imaging

Podiatry

Behavioral Health

Other (please specify)

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* 2. Was this your first visit?

Yes

Other (please specify)

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* 3. Do you have a primary care physician that you see for regular check-ups?

Yes

Don't Know

Other (please specify)

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* 4. Tell us about your recent visit. How many minutes did you wait past your scheduled appointment time?

Less than 5 minutes

More than 10 minutes

More than 20 minutes

More than 30 minutes

More than 45 Minutes

Over 1 hour

Other (please specify)

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* 5. How many minutes did you wait in the exam room before you were seen by a doctor?

Less than 5 minutes

More than 10 minutes

More than 20 minutes

More than 30 minutes

More than 45 Minutes

Over 1 hour

Other (please specify)

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* 6. Please rate the services you received from our team of physicians and staff. Select the responses that best describes your experience.

	Poor	Fair	Good	Very Good	Excellent
When scheduling your appointment, how well did the scheduler take your needs and schedule into consideration	When scheduling your appointment, how well did the scheduler take your needs and schedule into consideration Poor	When scheduling your appointment, how well did the scheduler take your needs and schedule into consideration Fair	When scheduling your appointment, how well did the scheduler take your needs and schedule into consideration Good	When scheduling your appointment, how well did the scheduler take your needs and schedule into consideration Very Good	When scheduling your appointment, how well did the scheduler take your needs and schedule into consideration Excellent
The level of courtesy and professionalism provided by the staff who registered you for the visit	The level of courtesy and professionalism provided by the staff who registered you for the visit Poor	The level of courtesy and professionalism provided by the staff who registered you for the visit Fair	The level of courtesy and professionalism provided by the staff who registered you for the visit Good	The level of courtesy and professionalism provided by the staff who registered you for the visit Very Good	The level of courtesy and professionalism provided by the staff who registered you for the visit Excellent
Your confidence in the physician/practitioner that provided the care or service	Your confidence in the physician/practitioner that provided the care or service Poor	Your confidence in the physician/practitioner that provided the care or service Fair	Your confidence in the physician/practitioner that provided the care or service Good	Your confidence in the physician/practitioner that provided the care or service Very Good	Your confidence in the physician/practitioner that provided the care or service Excellent
The amount of time the physician/practitioner spent with you	The amount of time the physician/practitioner spent with you Poor	The amount of time the physician/practitioner spent with you Fair	The amount of time the physician/practitioner spent with you Good	The amount of time the physician/practitioner spent with you Very Good	The amount of time the physician/practitioner spent with you Excellent
The level of concern and respect the physician/practitioner expressed for your condition that brought you in for your visit	The level of concern and respect the physician/practitioner expressed for your condition that brought you in for your visit Poor	The level of concern and respect the physician/practitioner expressed for your condition that brought you in for your visit Fair	The level of concern and respect the physician/practitioner expressed for your condition that brought you in for your visit Good	The level of concern and respect the physician/practitioner expressed for your condition that brought you in for your visit Very Good	The level of concern and respect the physician/practitioner expressed for your condition that brought you in for your visit Excellent
Explanations and information the physician/practitioner gave you about your problem or condition	Explanations and information the physician/practitioner gave you about your problem or condition Poor	Explanations and information the physician/practitioner gave you about your problem or condition Fair	Explanations and information the physician/practitioner gave you about your problem or condition Good	Explanations and information the physician/practitioner gave you about your problem or condition Very Good	Explanations and information the physician/practitioner gave you about your problem or condition Excellent
Physicians’/practitioners’ efforts to include you in the decisions about your care	Physicians’/practitioners’ efforts to include you in the decisions about your care Poor	Physicians’/practitioners’ efforts to include you in the decisions about your care Fair	Physicians’/practitioners’ efforts to include you in the decisions about your care Good	Physicians’/practitioners’ efforts to include you in the decisions about your care Very Good	Physicians’/practitioners’ efforts to include you in the decisions about your care Excellent
Likelihood of recommending the physician/practitioner to others	Likelihood of recommending the physician/practitioner to others Poor	Likelihood of recommending the physician/practitioner to others Fair	Likelihood of recommending the physician/practitioner to others Good	Likelihood of recommending the physician/practitioner to others Very Good	Likelihood of recommending the physician/practitioner to others Excellent
Overall hygiene of the staff to ensure your safety (washing hands, wearing protective gear as needed, sanitizing the exam room and equipment, etc.)	Overall hygiene of the staff to ensure your safety (washing hands, wearing protective gear as needed, sanitizing the exam room and equipment, etc.) Poor	Overall hygiene of the staff to ensure your safety (washing hands, wearing protective gear as needed, sanitizing the exam room and equipment, etc.) Fair	Overall hygiene of the staff to ensure your safety (washing hands, wearing protective gear as needed, sanitizing the exam room and equipment, etc.) Good	Overall hygiene of the staff to ensure your safety (washing hands, wearing protective gear as needed, sanitizing the exam room and equipment, etc.) Very Good	Overall hygiene of the staff to ensure your safety (washing hands, wearing protective gear as needed, sanitizing the exam room and equipment, etc.) Excellent
Ease of access to your health records, appointment schedule, and lab results online	Ease of access to your health records, appointment schedule, and lab results online Poor	Ease of access to your health records, appointment schedule, and lab results online Fair	Ease of access to your health records, appointment schedule, and lab results online Good	Ease of access to your health records, appointment schedule, and lab results online Very Good	Ease of access to your health records, appointment schedule, and lab results online Excellent
In general, how would you rate your experience with our providers and facilities	In general, how would you rate your experience with our providers and facilities Poor	In general, how would you rate your experience with our providers and facilities Fair	In general, how would you rate your experience with our providers and facilities Good	In general, how would you rate your experience with our providers and facilities Very Good	In general, how would you rate your experience with our providers and facilities Excellent

Other (please specify)

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* 7. If you had to decide today about renewing your enrollment with our services, would you?

Yes

Maybe

Please tell us why:

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* 8. Did you receive exceptional service?
Is there someone who provided extra care and attention to you during your visit?

Employee name:

Department:

Date of service:

Additional Information:

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* 9. Please describe how they went above and beyond for you by sharing your story with us:

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* 10. Would you provide your permission to share this information with our staff?

Yes

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* 11. Would you provide your permission for us to share this information in our communication materials including our website, social media and literature?

Yes

Healdsburg Hospital Patient Feedback Form

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* 1. Where was your last visit:

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* 2. Was this your first visit?

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* 3. Do you have a primary care physician that you see for regular check-ups?

Question Title

* 4. Tell us about your recent visit. How many minutes did you wait past your scheduled appointment time?

Question Title

* 5. How many minutes did you wait in the exam room before you were seen by a doctor?

Question Title

* 6. Please rate the services you received from our team of physicians and staff. Select the responses that best describes your experience.

Question Title

* 7. If you had to decide today about renewing your enrollment with our services, would you?

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* 8. Did you receive exceptional service?Is there someone who provided extra care and attention to you during your visit?

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* 9. Please describe how they went above and beyond for you by sharing your story with us:

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* 10. Would you provide your permission to share this information with our staff?

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* 11. Would you provide your permission for us to share this information in our communication materials including our website, social media and literature?

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* 12. Anything else you would like us to know?

* 8. Did you receive exceptional service?
Is there someone who provided extra care and attention to you during your visit?