Patient Satisfaction Survey

* 1. What is your age?

* 2. How long have you been going to your healthcare provider?

* 3. How long has it been since your most recent visit with your healthcare provider?

* 4. In the last 12 months, when you phoned your healthcare provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

* 5. In the last 12 months, did you phone your healthcare provider’s office with a medical question during regular office hours?

* 6. In the last 12 months, when you made an appointment for a check-up or routine care with your healthcare provider, how often did you get an appointment as soon as you needed?

* 7. In the last 12 months, when you phoned your healthcare provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

* 8. In the last 12 months, did you phone your healthcare provider’s office with a medical question after regular office hours?

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

* 10. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see your healthcare provider within 15 minutes of your appointment time?

* 11. During your most recent visit, did your healthcare provider explain things in a way that was easy to understand?

* 12. During your most recent visit, did your healthcare provider give you easy to understand information about these health questions or concerns?

* 13. During your most recent visit, did your healthcare provider listen carefully to you?

* 14. During your most recent visit, did your healthcare provider seem to know the important information about your medical history?

* 15. During your most recent visit, did your healthcare provider show respect for what you had to say?

* 16. During your most recent visit, did your healthcare provider spend enough time with you?

* 17. During your most recent visit, did your healthcare provider order a blood test, x-ray, or other test for you?

* 18. Did someone from your healthcare provider’s office follow up to give you those results?

* 19. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate your healthcare provider?

  10 Best provider possible 9 8 7 6 5 4 3 2 1 0 Worst provider possible
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* 20. During your most recent visit, did clerks and receptionists at your healthcare provider’s office treat you with courtesy and respect?

* 21. Would you recommend your healthcare provider’s office to your family and friends?

* 22. During your most recent visit, were clerks and receptionists at your healthcare provider’s office as helpful as you thought they should be?

* 23. What is the highest grade or level of school that you have completed?

* 24. Did someone help you complete this survey?

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

* 26. Do you have any other comments, questions, or concerns?

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