Exit Patient Experience Survey Question Title * 1. How was the appointment for your visit scheduled? in person I called the office The office called me Please rate each by circling the number that best describes your opinion Question Title * 2. How would you rate the length of time it took between making your appointment and the visit. Poor Fair Good Very Good Excellent Not Applicable/No Opinion Poor Fair Good Very Good Excellent Not Applicable/No Opinion Question Title * 3. How would you rate the helpfullness of the reception staff? (before and upon arrival for your exam) Poor Fair Good Very Good Excellent Not Applicable/No opinion Poor Fair Good Very Good Excellent Not Applicable/No opinion Question Title * 4. How would you rate the hours we are open? Poor Fair Good Very Good Excellent Not applicable/No opinion Poor Fair Good Very Good Excellent Not applicable/No opinion Question Title * 5. How would you rate the willingness of our staff to answer any of your questions? Poor Fair Good Very Good Excellent Not applicable/No opinion Poor Fair Good Very Good Excellent Not applicable/No opinion Question Title * 6. How would you rate the time and care the technologist took to explain your exam to you? Poor Fair Good Very Good Excellent Not applicable/No opinion Poor Fair Good Very Good Excellent Not applicable/No opinion Technologist Name/Exam Performed: Question Title * 7. Please rate your comfort level during your exam. (courtesy and respect you were given, friendliness and kindness) Poor Fair Good Very Good Excellent Not applicable/No opinion Poor Fair Good Very Good Excellent Not applicable/No opinion Question Title * 8. Please rate the thoroughness of the technologist to explain the end of your exam. (proceed to change and exit; book another appt before leaving; timeliness of reporting) Poor Fair Good Very Good Excellent Not applicable/No opinion Poor Fair Good Very Good Excellent Not applicable/No opinion Question Title * 9. Please rate the cleanliness and neatness of our clinic. Poor Fair Good Very Good Excellent Not applicable/No opinion Poor Fair Good Very Good Excellent Not applicable/No opinion Question Title * 10. Would you recommend the clinic to a friend or family member? Yes No Question Title * 11. Regarding your overall experience visiting our clinic, please list things that we are doing well. Question Title * 12. If there were some things you could change about this visit to improve it, what would they be? Done
