Recent visit feedback We would like to know how you feel about the services we provide. Question Title * 1. Ease of making appointments by phone Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 2. Your phone calls answered promptly Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 3. Appointment available within reasonable amount of time Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 4. Contacting us after-hours Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 5. Efficiency of check-in process Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 6. Waiting time in reception area Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 7. Waiting time in exam room Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 8. Your test results reported in a reasonable amount of time Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 9. Keeping you informed of delays during your appointment Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 10. Ease of getting a referral Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 11. Your provider listens to you Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 12. Your provider takes enough time with you Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 13. Your provider explains what you want to know Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 14. Your provider gives you good advice and treatments Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 15. Your provider helps you establish self management health care goals (ex. diet, exercise) Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 16. The nurse staff was friendly and helpful to you Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 17. The nurse staff answers your questions Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 18. Other office staff was friendly and helpful to you Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 19. Other office staff answers your questions Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 20. Hours of operation are convenient for you Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 21. Overall comfort of our facility Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 22. Adequate parking Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 23. Signage and direction easy to follow Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 24. Your overall satisfaction with our practice Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 25. Overall quality of your medical care Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 26. Overall rating of care from your provider Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 27. Overall rating of care from your nurse Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 28. Overall how likely would you be to recommend our practice to others Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 29. Have you had a referral to a specialist in the last month? Yes No Question Title * 30. If you have had a referral, how satisfied with the specialist were you? Poor Fair Good Very Good Excellent N/A Poor Fair Good Very Good Excellent N/A Question Title * 31. Specialist Name: Done
