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* 1. Which category below includes your age?

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* 2. How long have you been a patient in our practice?

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* 3. Which location do you use as your primary office?

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* 4. How satisfied were you with your last office visit with a physician/nurse practitioner?

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* 5. Do you feel our office staff is kind, courteous, and helpful?

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* 6. How likely are you to recommend our practice to others?

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* 7. Are you considering, or have you ever considered, leaving our practice to join another local practice?

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* 8. How interested are you in receiving electronic information about our practice?

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* 9. What services are you most likely to utilize on the Patient Portal?

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* 10. What area of our office do you feel needs the most improvement?

  Outstanding Average Below Average Needs Improvement
Medical Provider and/or Nurse Services
Appointment Scheduling
Check In Customer Service
Media Usage (website, Facebook)
Patient Portal
General Office Customer Service
Phone Etiquette
Referral Services
Lab Staff & Services
Billing Services

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* 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
Time spent in the waiting room prior to appointment
Time spent in the exam room waiting for the clinician
Coordination of care provided by your clinician to outside specialists/resources
Your clinician’s knowledge of the care received by outside specialists/resources

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* 12. What bothers you most about our practice, staff, procedures, etc?

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* 13. As a parent, what you would like us to be doing that we are not currently?

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* 14. How can we improve our practice as a whole?

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