Patient Satisfaction Survey

Dear Patient: As part of our ongoing efforts to provide the highest quality service to our patients we are very interested in receiving your feedback about the care you received from our office. Please take a few minutes to complete this survey and return it to us. Your response is very important to us. Your answers will be kept confidential and all results will be aggregated and utilized to improve patient care. Thank you in advance for your help.

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* 1. ACCESS TO THE CLINIC

	Very Satisfied	Satisfied	Not Satisfied or Dissatisfied	Dissatisfied	Very Dissatisfied	N/A
Ease of making your appointment by telephone	Ease of making your appointment by telephone Very Satisfied	Ease of making your appointment by telephone Satisfied	Ease of making your appointment by telephone Not Satisfied or Dissatisfied	Ease of making your appointment by telephone Dissatisfied	Ease of making your appointment by telephone Very Dissatisfied	Ease of making your appointment by telephone N/A
Ability to get an appointment as quickly as you wanted it	Ability to get an appointment as quickly as you wanted it Very Satisfied	Ability to get an appointment as quickly as you wanted it Satisfied	Ability to get an appointment as quickly as you wanted it Not Satisfied or Dissatisfied	Ability to get an appointment as quickly as you wanted it Dissatisfied	Ability to get an appointment as quickly as you wanted it Very Dissatisfied	Ability to get an appointment as quickly as you wanted it N/A
Ability to be seen on the day and time that works best for you	Ability to be seen on the day and time that works best for you Very Satisfied	Ability to be seen on the day and time that works best for you Satisfied	Ability to be seen on the day and time that works best for you Not Satisfied or Dissatisfied	Ability to be seen on the day and time that works best for you Dissatisfied	Ability to be seen on the day and time that works best for you Very Dissatisfied	Ability to be seen on the day and time that works best for you N/A
The time that you spent in the waiting room and exam room before seeing your doctor	The time that you spent in the waiting room and exam room before seeing your doctor Very Satisfied	The time that you spent in the waiting room and exam room before seeing your doctor Satisfied	The time that you spent in the waiting room and exam room before seeing your doctor Not Satisfied or Dissatisfied	The time that you spent in the waiting room and exam room before seeing your doctor Dissatisfied	The time that you spent in the waiting room and exam room before seeing your doctor Very Dissatisfied	The time that you spent in the waiting room and exam room before seeing your doctor N/A

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* 2. OUR STAFF

	Very Satisfied	Satisfied	Not Satisfied or Dissatisfied	Dissatisfied	Very Dissatisfied	N/A
The friendliness of the front desk staff	The friendliness of the front desk staff Very Satisfied	The friendliness of the front desk staff Satisfied	The friendliness of the front desk staff Not Satisfied or Dissatisfied	The friendliness of the front desk staff Dissatisfied	The friendliness of the front desk staff Very Dissatisfied	The friendliness of the front desk staff N/A
The caring and concern of the nurses/medical assistants	The caring and concern of the nurses/medical assistants Very Satisfied	The caring and concern of the nurses/medical assistants Satisfied	The caring and concern of the nurses/medical assistants Not Satisfied or Dissatisfied	The caring and concern of the nurses/medical assistants Dissatisfied	The caring and concern of the nurses/medical assistants Very Dissatisfied	The caring and concern of the nurses/medical assistants N/A

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* 3. COMMUNICATION

	Very Satisfied	Satisfied	Not Satisfied or Dissatisfied	Dissatisfied	Very Dissatisfied	N/A
The speed with which your telephone calls are answered	The speed with which your telephone calls are answered Very Satisfied	The speed with which your telephone calls are answered Satisfied	The speed with which your telephone calls are answered Not Satisfied or Dissatisfied	The speed with which your telephone calls are answered Dissatisfied	The speed with which your telephone calls are answered Very Dissatisfied	The speed with which your telephone calls are answered N/A
Your ability to get help or advice during office hours by telephone	Your ability to get help or advice during office hours by telephone Very Satisfied	Your ability to get help or advice during office hours by telephone Satisfied	Your ability to get help or advice during office hours by telephone Not Satisfied or Dissatisfied	Your ability to get help or advice during office hours by telephone Dissatisfied	Your ability to get help or advice during office hours by telephone Very Dissatisfied	Your ability to get help or advice during office hours by telephone N/A
The way your doctor listened to your concerns and showed understanding of your health condition	The way your doctor listened to your concerns and showed understanding of your health condition Very Satisfied	The way your doctor listened to your concerns and showed understanding of your health condition Satisfied	The way your doctor listened to your concerns and showed understanding of your health condition Not Satisfied or Dissatisfied	The way your doctor listened to your concerns and showed understanding of your health condition Dissatisfied	The way your doctor listened to your concerns and showed understanding of your health condition Very Dissatisfied	The way your doctor listened to your concerns and showed understanding of your health condition N/A
Your doctor's explanation of things in a way you could understand	Your doctor's explanation of things in a way you could understand Very Satisfied	Your doctor's explanation of things in a way you could understand Satisfied	Your doctor's explanation of things in a way you could understand Not Satisfied or Dissatisfied	Your doctor's explanation of things in a way you could understand Dissatisfied	Your doctor's explanation of things in a way you could understand Very Dissatisfied	Your doctor's explanation of things in a way you could understand N/A
Ease of understanding instructions regarding your medication and follow-up care	Ease of understanding instructions regarding your medication and follow-up care Very Satisfied	Ease of understanding instructions regarding your medication and follow-up care Satisfied	Ease of understanding instructions regarding your medication and follow-up care Not Satisfied or Dissatisfied	Ease of understanding instructions regarding your medication and follow-up care Dissatisfied	Ease of understanding instructions regarding your medication and follow-up care Very Dissatisfied	Ease of understanding instructions regarding your medication and follow-up care N/A
The availability of your health information such as test results	The availability of your health information such as test results Very Satisfied	The availability of your health information such as test results Satisfied	The availability of your health information such as test results Not Satisfied or Dissatisfied	The availability of your health information such as test results Dissatisfied	The availability of your health information such as test results Very Dissatisfied	The availability of your health information such as test results N/A

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* 4. CARE COORDINATION

	Very Satisfied	Satisfied	Not Satisfied or Dissatisfied	Dissatisfied	Very Dissatisfied	N/A
Your doctor's communication with other providers involved in your care	Your doctor's communication with other providers involved in your care Very Satisfied	Your doctor's communication with other providers involved in your care Satisfied	Your doctor's communication with other providers involved in your care Not Satisfied or Dissatisfied	Your doctor's communication with other providers involved in your care Dissatisfied	Your doctor's communication with other providers involved in your care Very Dissatisfied	Your doctor's communication with other providers involved in your care N/A
Your doctor's efforts to involve you in planning your own care	Your doctor's efforts to involve you in planning your own care Very Satisfied	Your doctor's efforts to involve you in planning your own care Satisfied	Your doctor's efforts to involve you in planning your own care Not Satisfied or Dissatisfied	Your doctor's efforts to involve you in planning your own care Dissatisfied	Your doctor's efforts to involve you in planning your own care Very Dissatisfied	Your doctor's efforts to involve you in planning your own care N/A
The quality and ease of use of the self-management tools given to you by the practice	The quality and ease of use of the self-management tools given to you by the practice Very Satisfied	The quality and ease of use of the self-management tools given to you by the practice Satisfied	The quality and ease of use of the self-management tools given to you by the practice Not Satisfied or Dissatisfied	The quality and ease of use of the self-management tools given to you by the practice Dissatisfied	The quality and ease of use of the self-management tools given to you by the practice Very Dissatisfied	The quality and ease of use of the self-management tools given to you by the practice N/A

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* 5. LIKELIHOOD TO RECOMMEND

	Would Definitely Recommend	Would Recommend	May or May Not Recommend	Would Not Recommend	Definitely Would Not Recommend
How likely are you to recommend our practice to your friends and family	How likely are you to recommend our practice to your friends and family Would Definitely Recommend	How likely are you to recommend our practice to your friends and family Would Recommend	How likely are you to recommend our practice to your friends and family May or May Not Recommend	How likely are you to recommend our practice to your friends and family Would Not Recommend	How likely are you to recommend our practice to your friends and family Definitely Would Not Recommend

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* 6. Please let us know the reasons you would or would not recommend our practice to others.

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* 7. Please let us know if there is anything we can do to improve our services to you.

Your answers are confidential, but please share some information with us to help us tailor our services better.

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* 8. Gender

Male

Female

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* 9. Age

18-29

30-39

40-49

50-59

60-65

65-75

75-85

Over 85

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* 10. Primary Language

English

Spanish

French

Other (please specify)

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* 11. Do you have health insurance:

Yes

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* 12. Thank you so much for providing us with this valuable information that we will use to improve your care. We are glad that you are our patient!

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* 13. My Practice is...

Bull City Family Medicine and Pediatrics

Cornerstone Pediatrics and Adolescent Medicine

Durham Family Medicine

North Raleigh Pediatrics

Larry Berman, MD

Biltmore Family Medicine

Cape Fear Family Medical Care

Carley Family Care

Carolina Prime Internal Medicine

Family Care of Fairview

Family Care of Black Mountain

Family Care of Old Fort

Health Park Pediatrics

Horizon Family Medicine (Clayton)

Horizon Family Medicine (Four Oaks)

Horizon Family Medicine (Riverwood)

Horizon Family Medicine (Smithfield)

Heritage Urgent and Primary Care

Masonboro Family Medicine

Roxboro Family Medicine and Immediate Care

Seaside Wellness of Shallotte

Solid Rock Family Medicine

Spindale Family Practice