* 1. How likely is it that you would recommend your provider to a friend or family member?

Not at all likely
Extremely likely

* 2. Overall, how satisfied or dissatisfied were you with your last visit to our office?

* 3. How easy or difficult was it to schedule your appointment at a time that was convenient for you?

* 4. How convenient was the appointment time you were able to get?

* 5. In your opinion, how convenient is the location of our office?

* 6. Overall, how would you rate the service you received from the staff at our office?

* 7. How comfortable was the lobby and waiting area?

* 8. Did your appointment with your provider start early, late or on time?

* 9. Overall, how would you rate the care you received from your provider?

* 10. How much do you trust your provider to make medical decisions that are in your best interests?

* 11. How well did your provider listen to your needs?

* 12. How well did your provider answer your questions?

* 13. How well did your provider explain your treatment options?

* 14. How well did your provider explain your follow-up care?

* 15. How satisfied or dissatisfied were you with the amount of time your provider spent with you addressing your needs?

* 16. Is there anything we could have done to improve your last visit?

T