* 1. How likely is it that you would recommend your doctor to a friend or family member?

Not at all likely
Extremely likely

* 2. Where did your office visit take place?

* 3. Which provider did you see at our office?

* 4. Overall, how satisfied or dissatisfied were you with your last visit to our office?

* 5. How easy or difficult was it to schedule your appointment with our office?

* 6. If you left a message for our office, how timely did we respond to your question/need?

* 7. Overall, how would you rate the service you received from the staff at our office?

* 8. How comfortable and presentable was the lobby and waiting area?

* 9. Did your appointment with your provider start early, late or on time?

* 10. Overall, how would you rate the care you received from your provider?

* 11. How much do you trust your provider to make medical decisions that are in your best interests?

* 12. How well did your provider listen to your needs?

* 13. How well did your provider answer your questions?

* 14. How well did your provider explain your treatment options?

* 15. How well did your provider explain your follow-up care?

* 16. How satisfied or dissatisfied were you with the amount of time your provider spent with you addressing your needs?

* 17. Is there anything we could have done to improve your last visit?

* 18. What is your name (optional) - please include if you have left comments that might require our feedback/response?

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