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EMHC Quality Assurance 10 Questions Patient Satisfaction Survey
1.
Date of service:
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2.
Select the Clinic or the purpose for your visit that most applies ?
Behavioral Health
Dental
Diabetes Building
Elbowoods Memorial Health Center
Lab Only Visit
Mandaree
Optometry
Parshall
Pharmacy Visit
Public Health Clinic
Radiology/Ultrasound/CT scan
Twin Buttes
White Shield
Patient Referred Services PRC
Medical Records
Physical Therapy
3.
On a scale of 0 to 10,
How likely is it that you would recommend Clinic to a friend or colleague?
0 for Not at all likely, 10 for Extremely likely
Not at all likely
Extremely likely
0
1
2
3
4
5
6
7
8
9
10
4.
How would you rate the cleanliness of our Clinic or Facility ?
Above average
Average
Below average
5.
How would you rate your overall quality of your Visit ?
Extremely professional
Very professional
Somewhat professional
Not so professional
Not at all professional
6.
How would you rate your experience with checking in for your Visit ?
Very easy
Easy
Neither easy nor difficult
Difficult
Very difficult
7.
Did the staff explain and provide clear answers to any of your questions ?
Extremely clear
Very clear
Somewhat clear
Not so clear
Not at all clear
8.
How would you rate our customer service ?
Extremely friendly
Very friendly
Somewhat friendly
Not so friendly
Not at all friendly
9.
How long have you been a patient at our facility?
Less than six months
Six months to a year
1 - 2 years
3 or more years
10.
How would rate our parking distance from the front entrance ?
Too short
About the right length
Too long
None of the above
Current Progress,
0 of 10 answered
