Patient Experience Survey

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* 1. What is your age?

1-17

18-29

30-39

40-49

50-59

60-69

70-79

80 and up

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* 2. What is your gender?

Female

Male

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* 3. How did you hear about our office?

I am an established patient

Referred by Family Doctor

Referred by Emergency Room/Urgent Care

Referred by Friend/Family member

Internet search

Phone book

Other (please specify)

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* 4. Date of Office Visit:

Date

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* 5. Who did you see during your office visit?

Dr. Thomas Wise

Dr. John Zoller

Dr. Stephen Martenson

Dr. Abbey Gore

Dr. Matthew Mantell

Alyson Humphreys, PA-C

Tammy Earhart, PA-C

Ashley Warren, PA-C

Eric Fisher, PA-C

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* 6. If you called our office to make an appointment, please rate your experience...

	Excellent	Very Good	Good	Fair	Poor	N/A
Courtesy and professionalism of staff	Courtesy and professionalism of staff Excellent	Courtesy and professionalism of staff Very Good	Courtesy and professionalism of staff Good	Courtesy and professionalism of staff Fair	Courtesy and professionalism of staff Poor	Courtesy and professionalism of staff N/A
If a message was left, received a return call within 24-48 business hours	If a message was left, received a return call within 24-48 business hours Excellent	If a message was left, received a return call within 24-48 business hours Very Good	If a message was left, received a return call within 24-48 business hours Good	If a message was left, received a return call within 24-48 business hours Fair	If a message was left, received a return call within 24-48 business hours Poor	If a message was left, received a return call within 24-48 business hours N/A
Ease of scheduling an appointment convenient to your schedule	Ease of scheduling an appointment convenient to your schedule Excellent	Ease of scheduling an appointment convenient to your schedule Very Good	Ease of scheduling an appointment convenient to your schedule Good	Ease of scheduling an appointment convenient to your schedule Fair	Ease of scheduling an appointment convenient to your schedule Poor	Ease of scheduling an appointment convenient to your schedule N/A
Length of time between scheduling an appointment and the appointment date	Length of time between scheduling an appointment and the appointment date Excellent	Length of time between scheduling an appointment and the appointment date Very Good	Length of time between scheduling an appointment and the appointment date Good	Length of time between scheduling an appointment and the appointment date Fair	Length of time between scheduling an appointment and the appointment date Poor	Length of time between scheduling an appointment and the appointment date N/A

Comments

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* 7. When you arrived for your appointment...

	Excellent	Very Good	Good	Fair	Poor	N/A
Courtesy and professionalism of receptionist(s)	Courtesy and professionalism of receptionist(s) Excellent	Courtesy and professionalism of receptionist(s) Very Good	Courtesy and professionalism of receptionist(s) Good	Courtesy and professionalism of receptionist(s) Fair	Courtesy and professionalism of receptionist(s) Poor	Courtesy and professionalism of receptionist(s) N/A
Billing and insurance questions were addressed	Billing and insurance questions were addressed Excellent	Billing and insurance questions were addressed Very Good	Billing and insurance questions were addressed Good	Billing and insurance questions were addressed Fair	Billing and insurance questions were addressed Poor	Billing and insurance questions were addressed N/A
Length of wait in reception area	Length of wait in reception area Excellent	Length of wait in reception area Very Good	Length of wait in reception area Good	Length of wait in reception area Fair	Length of wait in reception area Poor	Length of wait in reception area N/A
Appearance and comfort of reception area	Appearance and comfort of reception area Excellent	Appearance and comfort of reception area Very Good	Appearance and comfort of reception area Good	Appearance and comfort of reception area Fair	Appearance and comfort of reception area Poor	Appearance and comfort of reception area N/A

Comments

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* 8. When you were in the exam room...

	Excellent	Very Good	Good	Fair	Poor	N/A
Length of wait in the exam room	Length of wait in the exam room Excellent	Length of wait in the exam room Very Good	Length of wait in the exam room Good	Length of wait in the exam room Fair	Length of wait in the exam room Poor	Length of wait in the exam room N/A
Courtesy and professionalism of nursing staff	Courtesy and professionalism of nursing staff Excellent	Courtesy and professionalism of nursing staff Very Good	Courtesy and professionalism of nursing staff Good	Courtesy and professionalism of nursing staff Fair	Courtesy and professionalism of nursing staff Poor	Courtesy and professionalism of nursing staff N/A
Courtesy and professionalism of X-ray staff	Courtesy and professionalism of X-ray staff Excellent	Courtesy and professionalism of X-ray staff Very Good	Courtesy and professionalism of X-ray staff Good	Courtesy and professionalism of X-ray staff Fair	Courtesy and professionalism of X-ray staff Poor	Courtesy and professionalism of X-ray staff N/A
If cast was applied, education on cast care was explained clearly	If cast was applied, education on cast care was explained clearly Excellent	If cast was applied, education on cast care was explained clearly Very Good	If cast was applied, education on cast care was explained clearly Good	If cast was applied, education on cast care was explained clearly Fair	If cast was applied, education on cast care was explained clearly Poor	If cast was applied, education on cast care was explained clearly N/A
The explanation of your options, cost, and use of Durable Medical Equipment (such as crutches, slings or braces)	The explanation of your options, cost, and use of Durable Medical Equipment (such as crutches, slings or braces) Excellent	The explanation of your options, cost, and use of Durable Medical Equipment (such as crutches, slings or braces) Very Good	The explanation of your options, cost, and use of Durable Medical Equipment (such as crutches, slings or braces) Good	The explanation of your options, cost, and use of Durable Medical Equipment (such as crutches, slings or braces) Fair	The explanation of your options, cost, and use of Durable Medical Equipment (such as crutches, slings or braces) Poor	The explanation of your options, cost, and use of Durable Medical Equipment (such as crutches, slings or braces) N/A

Comments

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* 9. If you were scheduled for surgery, diagnostic test or special procedure (MRI, CT, injection series)...

	Excellent	Very Good	Good	Fair	Poor	N/A
Courtesy and professionalism of scheduling team member(s)	Courtesy and professionalism of scheduling team member(s) Excellent	Courtesy and professionalism of scheduling team member(s) Very Good	Courtesy and professionalism of scheduling team member(s) Good	Courtesy and professionalism of scheduling team member(s) Fair	Courtesy and professionalism of scheduling team member(s) Poor	Courtesy and professionalism of scheduling team member(s) N/A
If a message was left for scheduler, received a call back within 48 business hours	If a message was left for scheduler, received a call back within 48 business hours Excellent	If a message was left for scheduler, received a call back within 48 business hours Very Good	If a message was left for scheduler, received a call back within 48 business hours Good	If a message was left for scheduler, received a call back within 48 business hours Fair	If a message was left for scheduler, received a call back within 48 business hours Poor	If a message was left for scheduler, received a call back within 48 business hours N/A
Timeliness of scheduling test or special procedure (within 7 business days)	Timeliness of scheduling test or special procedure (within 7 business days) Excellent	Timeliness of scheduling test or special procedure (within 7 business days) Very Good	Timeliness of scheduling test or special procedure (within 7 business days) Good	Timeliness of scheduling test or special procedure (within 7 business days) Fair	Timeliness of scheduling test or special procedure (within 7 business days) Poor	Timeliness of scheduling test or special procedure (within 7 business days) N/A
Timeliness of scheduling Total Joint surgery (dependent on pre-operative screening)	Timeliness of scheduling Total Joint surgery (dependent on pre-operative screening) Excellent	Timeliness of scheduling Total Joint surgery (dependent on pre-operative screening) Very Good	Timeliness of scheduling Total Joint surgery (dependent on pre-operative screening) Good	Timeliness of scheduling Total Joint surgery (dependent on pre-operative screening) Fair	Timeliness of scheduling Total Joint surgery (dependent on pre-operative screening) Poor	Timeliness of scheduling Total Joint surgery (dependent on pre-operative screening) N/A
Timeliness of scheduling surgery - excluding Total Joints (notified of surgery date within 3 business days)	Timeliness of scheduling surgery - excluding Total Joints (notified of surgery date within 3 business days) Excellent	Timeliness of scheduling surgery - excluding Total Joints (notified of surgery date within 3 business days) Very Good	Timeliness of scheduling surgery - excluding Total Joints (notified of surgery date within 3 business days) Good	Timeliness of scheduling surgery - excluding Total Joints (notified of surgery date within 3 business days) Fair	Timeliness of scheduling surgery - excluding Total Joints (notified of surgery date within 3 business days) Poor	Timeliness of scheduling surgery - excluding Total Joints (notified of surgery date within 3 business days) N/A

Comments

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* 10. Please rate your experience with the Physician, PA, or NP:

	Excellent	Very Good	Good	Fair	Poor	N/A
Knowledgable and Professional	Knowledgable and Professional Excellent	Knowledgable and Professional Very Good	Knowledgable and Professional Good	Knowledgable and Professional Fair	Knowledgable and Professional Poor	Knowledgable and Professional N/A
Listened to me; showed concern and respect	Listened to me; showed concern and respect Excellent	Listened to me; showed concern and respect Very Good	Listened to me; showed concern and respect Good	Listened to me; showed concern and respect Fair	Listened to me; showed concern and respect Poor	Listened to me; showed concern and respect N/A
Explained things in a way I could understand	Explained things in a way I could understand Excellent	Explained things in a way I could understand Very Good	Explained things in a way I could understand Good	Explained things in a way I could understand Fair	Explained things in a way I could understand Poor	Explained things in a way I could understand N/A
Spent adequate time with me and answered all my questions	Spent adequate time with me and answered all my questions Excellent	Spent adequate time with me and answered all my questions Very Good	Spent adequate time with me and answered all my questions Good	Spent adequate time with me and answered all my questions Fair	Spent adequate time with me and answered all my questions Poor	Spent adequate time with me and answered all my questions N/A
Provided written/verbal education on my condition	Provided written/verbal education on my condition Excellent	Provided written/verbal education on my condition Very Good	Provided written/verbal education on my condition Good	Provided written/verbal education on my condition Fair	Provided written/verbal education on my condition Poor	Provided written/verbal education on my condition N/A

Comments

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* 11. Would you refer a family member or friend to our office?

Yes

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* 12. What did you like best about your visit?

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* 13. What did you like least about your visit? How can we improve?

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* 14. May we contact you for permission to use your responses as a patient testimonial?

Yes

If Yes, please provide your Name, Phone #