* 1. How satisfied are you with the following

  Extremely Dissatisfied Very Dissatisfied Satisfied Very Satisfied Extremely Satisfied
Ease of making appointment for checkup (physical exams, well visits, routine follow-up appointments?
Ease of making appointments for sickness?
Ease in contacting your doctor when our office is closed (nights and weekends)?
The time it takes someone from our office to respond when you call the office with an urgent problem?
Waiting time in our office?
Ease in obtaining follow-up information and care (test results, medicines, and care instructions)?
Overall medical care at our office?
Our office's appearance?
Our office's convenience (location, parking, hours, office layout)?
The way we teach you about improving your health?
The way your doctor involves other doctors and caregivers in your care when needed?

* 2. 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?

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

Not at all likely
Extremely likely

* 4. What is your age?

* 5. Are you male or female?

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

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

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

* 9. 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?

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

* 11. Did someone help you complete this survey?

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

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

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

* 15. Patient's Name (Optional):

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