* 1. When did you last visit our hospital?

* 2. How easy and pleasant was it to make the appointment?

* 3. What was the purpose of your visit?

* 4. Were your concerns addressed to your satisfaction?

* 5. Did your appointment start early, late or on time?

* 6. Which doctor did you see?

* 7. If not here for an appointment, were your needs attended to in a timely fashion?

* 8. How helpful and friendly was our reception staff?

* 9. How helpful and friendly was our exam room staff?

* 10. How helpful and friendly was your doctor?

* 11. What could we have done to improve your last visit?

* 12. Would you like us to contact you in regard to this survey?

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