* 1. What is your age?

* 2. What is your gender?

* 3. How long have you been a patient of this office?

* 4. Who is your primary physician?

* 5. How many times have you visited this doctor's office in the past 12 months?

* 6. What is the reason that you chose our practice?

* 7. How satisfied are you with the following?

  Extremely Dissatisfied Very Dissatisfied Satisfied Very Satisfied Extremely Satisfied
Ease of making appointment for physicals or routine follow up?
Ease of making an appointment for sickness?
Ease of contacting a doctor when we are closed on nights and weekends?
How would you rate the waiting time to see your doctor?
Satisfaction with the physicians explanation of your plan of care?
Communication about ways to improve your health?
Satisfaction with office appearance and cleanliness?
Caring attitude of your physician?
Caring attitude of nursing staff?
Caring attitude of front office staff?

* 8. Please answer the following

  Very Likely Likely Somewhat Likely
How likely would you recommend your doctor to your friends or family?

* 9. What do you like the most about Rio Family Medicine? What can we do to improve?

Thank you for taking the time to give us your feedback. 
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