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* 1. Which Provider (Doctor or Nurse Practitioner) did you see at your last office visit?

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* 2. Which Location were you seen for your appointment

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* 3. Who is the payer for your visit?

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* 4. Gender?

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* 5. Race?

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* 6. Which category best describes the age of the patient?

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* 7. Ease of Getting Care

  Excellent Good Fair Poor
Ability of getting an appointment
Ability of getting a same day appointment
Convenient hours of operations
Convenient locations

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* 8. Do you understand you can reach the office in the evening, weekends or holidays by calling our office number and getting the number for our answering service?

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* 9. Phone calls

  Excellent Good Fair Poor
Phone calls get through easily
Calls are quickly returned

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* 10. Receiving a return call from our offices

  N/A 0-4 Hours 4-8 Hours Greater than One Day Greater than Two Days
Calls requesting medication refills
Calls for information about a referral
Calls asking medical questions
Calls about billing issues

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* 11. Waiting times

  N/A Less than 5 minutes 5-10 minutes 10-20 minutes 20-30 minutes 30-40 minutes More than 40 minutes
Average time on hold when calling in
How many minutes did you spend checking in at the Front Desk
How many minutes spent in the waiting room
How many minutes did you spend in the exam room before seeing the provider
After seeing the provider how many minutes did you wait in the exam room
How many minutes did you spend checking out
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