* 1. Today's Date:


* 2. Type of Appointment

* 3. Did you get your appointment as soon as you needed it.

* 4. Which Provider was your appointment with?

* 5. Did the office staff treat you with dignity and respect

* 6. Were you seen within 15 minutes of your appointment time

* 7. Did the nurse treat you with courtesy and respect

* 8. Did your physician listen carefully to what you had to say

* 9. Did your provider spend enough time with you during your appointment

* 10. Physicians and nurses care for me as a "whole person" rather than just the illness for which I present during my visit.

* 11. My physician coordinates my care appropriately with other physicians/specialists and required testing services

* 12. Please provide any additional comments about your visit