Patient Satisfaction Survey: We would like to know how you feel about the services we provide in order to meet your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential.

Question Title

* 1. Demographics

	Your Age	Your Sex	Your Race	Your Ethnicity	Facility You Are Seen At	Service
About You:	About You: Your Age menu	About You: Your Sex menu	About You: Your Race menu	About You: Your Ethnicity menu	About You: Facility You Are Seen At menu	About You: Service menu

	Excellent	Good	Fair	Poor	N/A
Ability to get in to be seen	Ability to get in to be seen Excellent	Ability to get in to be seen Good	Ability to get in to be seen Fair	Ability to get in to be seen Poor	Ability to get in to be seen N/A
Hours Center is open	Hours Center is open Excellent	Hours Center is open Good	Hours Center is open Fair	Hours Center is open Poor	Hours Center is open N/A
Convenience of Center's location	Convenience of Center's location Excellent	Convenience of Center's location Good	Convenience of Center's location Fair	Convenience of Center's location Poor	Convenience of Center's location N/A
Prompt return of phone calls	Prompt return of phone calls Excellent	Prompt return of phone calls Good	Prompt return of phone calls Fair	Prompt return of phone calls Poor	Prompt return of phone calls N/A

Excellent

Good

Fair

Poor

N/A

Ability to get in to be seen

Ability to get in to be seen Excellent

Ability to get in to be seen Good

Ability to get in to be seen Fair

Ability to get in to be seen Poor

Ability to get in to be seen N/A

Hours Center is open

Hours Center is open Excellent

Hours Center is open Good

Hours Center is open Fair

Hours Center is open Poor

Hours Center is open N/A

Convenience of Center's location

Convenience of Center's location Excellent

Convenience of Center's location Good

Convenience of Center's location Fair

Convenience of Center's location Poor

Convenience of Center's location N/A

Prompt return of phone calls

Prompt return of phone calls Excellent

Prompt return of phone calls Good

Prompt return of phone calls Fair

Prompt return of phone calls Poor

Prompt return of phone calls N/A

	Excellent	Good	Fair	Poor	N/A
Time in waiting room	Time in waiting room Excellent	Time in waiting room Good	Time in waiting room Fair	Time in waiting room Poor	Time in waiting room N/A
Time in exam room	Time in exam room Excellent	Time in exam room Good	Time in exam room Fair	Time in exam room Poor	Time in exam room N/A
Waiting for tests to be performed	Waiting for tests to be performed Excellent	Waiting for tests to be performed Good	Waiting for tests to be performed Fair	Waiting for tests to be performed Poor	Waiting for tests to be performed N/A
Waiting for test results	Waiting for test results Excellent	Waiting for test results Good	Waiting for test results Fair	Waiting for test results Poor	Waiting for test results N/A

Excellent

Good

Fair

Poor

N/A

Time in waiting room

Time in waiting room Excellent

Time in waiting room Good

Time in waiting room Fair

Time in waiting room Poor

Time in waiting room N/A

Time in exam room

Time in exam room Excellent

Time in exam room Good

Time in exam room Fair

Time in exam room Poor

Time in exam room N/A

Waiting for tests to be performed

Waiting for tests to be performed Excellent

Waiting for tests to be performed Good

Waiting for tests to be performed Fair

Waiting for tests to be performed Poor

Waiting for tests to be performed N/A

Waiting for test results

Waiting for test results Excellent

Waiting for test results Good

Waiting for test results Fair

Waiting for test results Poor

Waiting for test results N/A

	Excellent	Good	Fair	Poor	N/A
Listens to you	Listens to you Excellent	Listens to you Good	Listens to you Fair	Listens to you Poor	Listens to you N/A
Takes enough time with you	Takes enough time with you Excellent	Takes enough time with you Good	Takes enough time with you Fair	Takes enough time with you Poor	Takes enough time with you N/A
Explains what you need to know	Explains what you need to know Excellent	Explains what you need to know Good	Explains what you need to know Fair	Explains what you need to know Poor	Explains what you need to know N/A
Gives you good advice and treatment	Gives you good advice and treatment Excellent	Gives you good advice and treatment Good	Gives you good advice and treatment Fair	Gives you good advice and treatment Poor	Gives you good advice and treatment N/A

Excellent

Good

Fair

Poor

N/A

Listens to you

Listens to you Excellent

Listens to you Good

Listens to you Fair

Listens to you Poor

Listens to you N/A

Takes enough time with you

Takes enough time with you Excellent

Takes enough time with you Good

Takes enough time with you Fair

Takes enough time with you Poor

Takes enough time with you N/A

Explains what you need to know

Explains what you need to know Excellent

Explains what you need to know Good

Explains what you need to know Fair

Explains what you need to know Poor

Explains what you need to know N/A

Gives you good advice and treatment

Gives you good advice and treatment Excellent

Gives you good advice and treatment Good

Gives you good advice and treatment Fair

Gives you good advice and treatment Poor

Gives you good advice and treatment N/A

	Excellent	Good	Fair	Poor	N/A
Friendly, helpful and to you	Friendly, helpful and to you Excellent	Friendly, helpful and to you Good	Friendly, helpful and to you Fair	Friendly, helpful and to you Poor	Friendly, helpful and to you N/A
Answers your questions	Answers your questions Excellent	Answers your questions Good	Answers your questions Fair	Answers your questions Poor	Answers your questions N/A

Excellent

Good

Fair

Poor

N/A

Friendly, helpful and to you

Friendly, helpful and to you Excellent

Friendly, helpful and to you Good

Friendly, helpful and to you Fair

Friendly, helpful and to you Poor

Friendly, helpful and to you N/A

Answers your questions

Answers your questions Excellent

Answers your questions Good

Answers your questions Fair

Answers your questions Poor

Answers your questions N/A

	Excellent	Good	Fair	Poor	N/A
Coordinates your plan of care and treatment	Coordinates your plan of care and treatment Excellent	Coordinates your plan of care and treatment Good	Coordinates your plan of care and treatment Fair	Coordinates your plan of care and treatment Poor	Coordinates your plan of care and treatment N/A
Monitors, follow-up, and responds to changes in your health	Monitors, follow-up, and responds to changes in your health Excellent	Monitors, follow-up, and responds to changes in your health Good	Monitors, follow-up, and responds to changes in your health Fair	Monitors, follow-up, and responds to changes in your health Poor	Monitors, follow-up, and responds to changes in your health N/A
Ease of getting a referral to a specialists	Ease of getting a referral to a specialists Excellent	Ease of getting a referral to a specialists Good	Ease of getting a referral to a specialists Fair	Ease of getting a referral to a specialists Poor	Ease of getting a referral to a specialists N/A
Assists with managing your medications	Assists with managing your medications Excellent	Assists with managing your medications Good	Assists with managing your medications Fair	Assists with managing your medications Poor	Assists with managing your medications N/A

Excellent

Good

Fair

Poor

N/A

Coordinates your plan of care and treatment

Coordinates your plan of care and treatment Excellent

Coordinates your plan of care and treatment Good

Coordinates your plan of care and treatment Fair

Coordinates your plan of care and treatment Poor

Coordinates your plan of care and treatment N/A

Monitors, follow-up, and responds to changes in your health

Monitors, follow-up, and responds to changes in your health Excellent

Monitors, follow-up, and responds to changes in your health Good

Monitors, follow-up, and responds to changes in your health Fair

Monitors, follow-up, and responds to changes in your health Poor

Monitors, follow-up, and responds to changes in your health N/A

Ease of getting a referral to a specialists

Ease of getting a referral to a specialists Excellent

Ease of getting a referral to a specialists Good

Ease of getting a referral to a specialists Fair

Ease of getting a referral to a specialists Poor

Ease of getting a referral to a specialists N/A

Assists with managing your medications

Assists with managing your medications Excellent

Assists with managing your medications Good

Assists with managing your medications Fair

Assists with managing your medications Poor

Assists with managing your medications N/A

	Excellent	Good	Fair	Poor	N/A
Friendly and helpful to you	Friendly and helpful to you Excellent	Friendly and helpful to you Good	Friendly and helpful to you Fair	Friendly and helpful to you Poor	Friendly and helpful to you N/A
Answers your questions	Answers your questions Excellent	Answers your questions Good	Answers your questions Fair	Answers your questions Poor	Answers your questions N/A

Excellent

Good

Fair

Poor

N/A

Friendly and helpful to you

Friendly and helpful to you Excellent

Friendly and helpful to you Good

Friendly and helpful to you Fair

Friendly and helpful to you Poor

Friendly and helpful to you N/A

Answers your questions

Answers your questions Excellent

Answers your questions Good

Answers your questions Fair

Answers your questions Poor

Answers your questions N/A

	Excellent	Good	Fair	Poor	N/A
How much you pay	How much you pay Excellent	How much you pay Good	How much you pay Fair	How much you pay Poor	How much you pay N/A
Explanation of charges	Explanation of charges Excellent	Explanation of charges Good	Explanation of charges Fair	Explanation of charges Poor	Explanation of charges N/A
Collection of payment/money	Collection of payment/money Excellent	Collection of payment/money Good	Collection of payment/money Fair	Collection of payment/money Poor	Collection of payment/money N/A

Excellent

Good

Fair

Poor

N/A

How much you pay

How much you pay Excellent

How much you pay Good

How much you pay Fair

How much you pay Poor

How much you pay N/A

Explanation of charges

Explanation of charges Excellent

Explanation of charges Good

Explanation of charges Fair

Explanation of charges Poor

Explanation of charges N/A

Collection of payment/money

Collection of payment/money Excellent

Collection of payment/money Good

Collection of payment/money Fair

Collection of payment/money Poor

Collection of payment/money N/A

	Excellent	Good	Fair	Poor	N/A
Neat and clean building	Neat and clean building Excellent	Neat and clean building Good	Neat and clean building Fair	Neat and clean building Poor	Neat and clean building N/A
Ease of finding where to go	Ease of finding where to go Excellent	Ease of finding where to go Good	Ease of finding where to go Fair	Ease of finding where to go Poor	Ease of finding where to go N/A
Comfort and safety while waiting	Comfort and safety while waiting Excellent	Comfort and safety while waiting Good	Comfort and safety while waiting Fair	Comfort and safety while waiting Poor	Comfort and safety while waiting N/A
Privacy	Privacy Excellent	Privacy Good	Privacy Fair	Privacy Poor	Privacy N/A

Excellent

Good

Fair

Poor

N/A

Neat and clean building

Neat and clean building Excellent

Neat and clean building Good

Neat and clean building Fair

Neat and clean building Poor

Neat and clean building N/A

Ease of finding where to go

Ease of finding where to go Excellent

Ease of finding where to go Good

Ease of finding where to go Fair

Ease of finding where to go Poor

Ease of finding where to go N/A

Comfort and safety while waiting

Comfort and safety while waiting Excellent

Comfort and safety while waiting Good

Comfort and safety while waiting Fair

Comfort and safety while waiting Poor

Comfort and safety while waiting N/A

Privacy

Privacy Excellent

Privacy Good

Privacy Fair

Privacy Poor

Privacy N/A

Question Title

* 10. Overall Findings

Would you refer your friends and relatives to us?

Is this your primary place to receive care?

What do you like best about the center?

What do you like least about the center?

Suggestions for improvement?

Patient Satisfaction Survey: We would like to know how you feel about the services we provide in order to meet your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential.

Question Title

* 1. Demographics

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* 2. Ease of getting care:

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* 3. Waiting:

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* 4. Provider staff: (Physician, Dentist, Physician Assistant, Nurse Practitioner)

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* 5. Nurses and Medical Assistants

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* 6. Staff Ability to Coordinate Your Care:

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* 7. All others( Receptionist, Billing, Accounts Receivable)

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* 8. Payment:

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* 9. Facility:

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* 10. Overall Findings