Post-Visit Patient Satisfaction Template Question Title * 1. How likely is it that you would recommend your provider to a friend or family member? NOT AT ALL LIKELY EXTREMELY LIKELY 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 OK Question Title * 2. How easy or difficult was it to schedule your appointment at a time that was convenient for you? Very easy Somewhat easy Neither easy nor difficult Somewhat difficult Very difficult OK Question Title * 3. How convenient was the appointment time you were able to get? Extremely convenient Very convenient Somewhat convenient Not so convenient Not at all convenient OK Question Title * 4. Overall, how would you rate the service you received from the staff at our office? Excellent Very good Good Fair Poor OK Question Title * 5. Did your appointment with your provider start early, late or on time? Very early Somewhat early On time Somewhat late Very late OK Question Title * 6. How much do you trust your provider to make medical decisions that are in your best interests? A great deal A lot A moderate amount A little Not at all OK Question Title * 7. How well did your provider listen to your needs? Extremely well Very well Somewhat well Not so well Not at all well OK Question Title * 8. How well did your provider explain your treatment options? Extremely well Very well Somewhat well Not so well Not at all well OK Question Title * 9. How well did your provider explain your follow-up care? Extremely well Very well Somewhat well Not so well Not at all well OK Question Title * 10. Is there anything we could have done to improve your last visit? OK DONE