Patient Satisfaction Survey
Clinic
1.)* I was a at .
2.)* The person who provided care was:
3.)* The appointment was:
4.)* If the appointment was scheduled, about how long did you have to wait (in the reception area and the exam room) before seeing the provider?
5.)* The office staff is friendly, courteous and helpful.
6.)* The medical assistants and nurses are sensitive and treat me with respect.
On a scale of 1 to 5 please rate the care you/your child/loved one received while at our clinic. (1 being very poor and 5 being excellent)
7.)* How would you rate how well the medical provider listened to what you had to say?
1. Very Poor 2. Poor 3. Fair 4. Good 5. Excellent
8.)* How would you rate how well the medical provider answered your questions?
1. Very Poor 2. Poor 3. Fair 4. Good 5. Excellent
9.)* How would you rate how well the medical provider offered advice on ways you can avoid illness and stay healthy?
1. Very Poor 2. Poor 3. Fair 4. Good 5. Excellent
10.)* How would you rate how well the medical provider explained your diagnosis in a way you could understand?
1. Very Poor 2. Poor 3. Fair 4. Good 5. Excellent
11.)* How would you rate the ease of accessing a specialist, if needed?
1. Very Poor 2. Poor 3. Fair 4. Good 5. Excellent
12.)* How would you rate the ease of accessing emergency care, if needed?
1. Very Poor 2. Poor 3. Fair 4. Good 5. Excellent
13.)* How would you rate the follow-up on medical procedures or test results, if performed?
1. Very Poor 2. Poor 3. Fair 4. Good 5. Excellent
14.)* How would you rate the way questions regarding your bill are answered?
1. Very Poor 2. Poor 3. Fair 4. Good 5. Excellent
15.)* How would you rate the cleanliness of the clinic waiting room, reception area, and exam rooms?
1. Very Poor 2. Poor 3. Fair 4. Good 5. Excellent
16.)* How would you rate the overall quality of care you received at the clinic?
1. Very Poor 2. Poor 3. Fair 4. Good 5. Excellent
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