How do you feel we are doing as a practice? Question Title * 1. Which category below includes your age? 17 or younger 18-20 21-29 30-39 40-49 50-59 60 or older Question Title * 2. How long have you been a patient in our practice? 0-1 year 1-5 years 5-10 years 10+ years Question Title * 3. Which location do you use as your primary office? Woburn office North Andover office Question Title * 4. How satisfied were you with your last office visit with a physician/nurse practitioner? Extremely satisfied Moderately satisfied Slightly satisfied Neither satisfied nor dissatisfied Slightly dissatisfied Moderately dissatisfied Extremely dissatisfied Question Title * 5. Do you feel our office staff is kind, courteous, and helpful? Yes No Sometimes Needs Improvement Question Title * 6. How likely are you to recommend our practice to others? Extremely likely Very likely Moderately likely Slightly likely Not at all likely Why or why not? (please specify) Question Title * 7. Are you considering, or have you ever considered, leaving our practice to join another local practice? Yes No If yes, why have you considered leaving? (please specify) Question Title * 8. How interested are you in receiving electronic information about our practice? Extremely interested Very interested Moderately interested Slightly interested Not at all interested What electronic avenues are you most interested in? (please specify) Question Title * 9. What services are you most likely to utilize on the Patient Portal? Appointment Scheduling Appointment Reminders Immunization Records Message to Medical Staff Refill Requests Lab Results Other (please specify) Question Title * 10. What area of our office do you feel needs the most improvement? Outstanding Average Below Average Needs Improvement Referral Services Referral Services Outstanding Referral Services Average Referral Services Below Average Referral Services Needs Improvement Media Usage (website, Facebook) Media Usage (website, Facebook) Outstanding Media Usage (website, Facebook) Average Media Usage (website, Facebook) Below Average Media Usage (website, Facebook) Needs Improvement Medical Provider and/or Nurse Services Medical Provider and/or Nurse Services Outstanding Medical Provider and/or Nurse Services Average Medical Provider and/or Nurse Services Below Average Medical Provider and/or Nurse Services Needs Improvement Check In Customer Service Check In Customer Service Outstanding Check In Customer Service Average Check In Customer Service Below Average Check In Customer Service Needs Improvement Phone Etiquette Phone Etiquette Outstanding Phone Etiquette Average Phone Etiquette Below Average Phone Etiquette Needs Improvement Lab Staff & Services Lab Staff & Services Outstanding Lab Staff & Services Average Lab Staff & Services Below Average Lab Staff & Services Needs Improvement Patient Portal Patient Portal Outstanding Patient Portal Average Patient Portal Below Average Patient Portal Needs Improvement Billing Services Billing Services Outstanding Billing Services Average Billing Services Below Average Billing Services Needs Improvement Appointment Scheduling Appointment Scheduling Outstanding Appointment Scheduling Average Appointment Scheduling Below Average Appointment Scheduling Needs Improvement General Office Customer Service General Office Customer Service Outstanding General Office Customer Service Average General Office Customer Service Below Average General Office Customer Service Needs Improvement Question Title * 11. Consider your visit(s) to our office in the last 12 months. Rate your experience for each of the following areas. Outstanding Average Below Average Needs Improvement Appointment obtained that worked with your schedule Appointment obtained that worked with your schedule Outstanding Appointment obtained that worked with your schedule Average Appointment obtained that worked with your schedule Below Average Appointment obtained that worked with your schedule Needs Improvement Time spent in the waiting room prior to appointment Time spent in the waiting room prior to appointment Outstanding Time spent in the waiting room prior to appointment Average Time spent in the waiting room prior to appointment Below Average Time spent in the waiting room prior to appointment Needs Improvement Time spent in the exam room waiting for the clinician Time spent in the exam room waiting for the clinician Outstanding Time spent in the exam room waiting for the clinician Average Time spent in the exam room waiting for the clinician Below Average Time spent in the exam room waiting for the clinician Needs Improvement Coordination of care provided by your clinician to outside specialists/resources Coordination of care provided by your clinician to outside specialists/resources Outstanding Coordination of care provided by your clinician to outside specialists/resources Average Coordination of care provided by your clinician to outside specialists/resources Below Average Coordination of care provided by your clinician to outside specialists/resources Needs Improvement Your clinician’s knowledge of the care received by outside specialists/resources Your clinician’s knowledge of the care received by outside specialists/resources Outstanding Your clinician’s knowledge of the care received by outside specialists/resources Average Your clinician’s knowledge of the care received by outside specialists/resources Below Average Your clinician’s knowledge of the care received by outside specialists/resources Needs Improvement Question Title * 12. What bothers you most about our practice, staff, procedures, etc? Question Title * 13. As a parent, what you would like us to be doing that we are not currently? Question Title * 14. How can we improve our practice as a whole? Done
