Question Title

* 1. How satisfied are you with the following:

  Extremely Dissatisfied Very Dissatisfied Satisfied Very Satisfied Extremely Satisfied
Ease of Making an Appointment for a Check-Up or Routine Follow-Up Appointment?
Ease of Making an Appointment for a Sick Visit?
Ease in Contacting Your Doctor when our Office is Closed?
Response Time when You Call with an Urgent Problem?
Wait Time in our Office?
Ease of Obtaining Follow-Up Info/Test Results?
Overall Medical Care at our Office?
Our Office's Convenience, such as Parking, Location and Hours?
The Way we Teach You About Improving Your Health?
Communication with Other Doctors/Caregivers in Your Health Care Team?

Question Title

* 2. Patient's Name (Optional):

Question Title

* 3. How caring would you say the following individuals are:

  Extremely Uncaring Very Uncaring Caring Very Caring Extremely Caring
Our doctors?
Our physician assistants?
Our nurse practitioners?
Our medical assistants?
Our office staff?
Our medical billing staff?

Question Title

* 4. How likely is it that you would recommend this practice to a friend or colleague?

Not at all likely
Extremely likely

Question Title

* 5. What is your age?

Question Title

* 6. Are you male or female?

Question Title

* 7. What is the highest level of school that you have completed?

Question Title

* 8. In the last 12 months, how many times did you visit your healthcare provider?

Question Title

* 9. How long have you been going to our practice?

Question Title

* 10. In the last 12 months, when you phoned our practice’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?

Question Title

* 11. In the last 12 months, did you make any appointments for a check-up or routine care with our practice?

Question Title

* 12. Did someone help you complete this survey?

Question Title

* 13. Do you currently have health insurance, or not?

Question Title

* 14. What is the name of your health plan?

Question Title

* 15. How did that person help you? Mark one or more.

Question Title

* 16. What office location were you seen in?

Question Title

* 17. What is your name? While this is optional, we would like to know who to speak to about these issues to make the situation right.

T