Please select the option or options that best express your feelings.

OUR FACILITIES

1. How Convenient Is Our Location?
Very Convenient Convenient Inconvenient Very Inconvenient

2. Is the parking adequate and conveniently located?
Very adequate Adequate Convenient Inadequate Inconvenient

3. How comfortable is our reception area?
Very Comfortable Comfortable Uncomfortable Very uncomfortable

4. Is the T.V. program appropriate and interesting?
Very Interesting Interesting Boring Inappropriate

5. What is your impression of our reception room, restroom, general areas?
Neat & Clean Clean, but untidy Dirty How can you work like this?

6. What is your impression of our exam rooms?
Neat & Clean Clean, but untidy Dirty Needs Attention Well equipped Equipment is old and worn

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FRONT OFFICE PERSONNEL

7. When you call our office, is the phone answered by the third or forth ring?
Always Usually Sometimes Rarely Hard to get through

8. How are you treated by the person answering your call?
Courteously Discourteously Rudely Not a human.

9. How would you rate our front office personnel? (receptionist, operators, appointment)
Friendly Courteously Caring Concerned Unfriendly Discourteous Rude Uncaring

10. How would you rate our Administrative personnel? (business office, office manager, medical records, accounting)
Friendly Courteously Caring Concerned Unfriendly Discourteous Rude Uncaring

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NURSING, MEDICAL ASSISTANTS, TRIAGE PERSONNEL

11. How would you rate our back office personnel?
Friendly Courteously Caring Concerned Knowledgeable Professional Unfriendly Discourteous Rude Uncaring Unskilled Unprofessional

12. Did they listen to you and help you with your problem?
Very well Adequately Not well at all Would not let me finish a sentence

13. Did they inform you as to the length of time before the doctor/practitioner would be in?
Frequently Adequately Not at all Had to find someone to ask

14. When calling the triage desk, did they answer your call promptly?
yes On hold a short time(less than 5 minutes) On hold a long time(between 5 to 10 minutes) On hold a very long time(more than 10 minutes) I had a birthday while on hold(over 20 minutes)

15. Did the back office personnel respect your privacy and modesty?
Very well somewhat not at all talked about me in the hall where I could hear.

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DOCTORS/NURSE PRACTITIONERS

16. How well do you feel your provider listens to you?
Very Well Adequately Not well at all Always rushed

17. How well does your provider explain your illness and treatment in terms you can understand?
Very Well Adequately Not well at all I am usually confused and afraid to ask questions.

18. How well does your provider answer your questions or concerns?
Very Well Adequately Not well at all I am usually confused

19. How well does your provider involve you in the treatment decision process and give you options, when available?
Very Well Adequately Not well at all Authoritarian and demanding

20. How satisfied were you with the medical treatment you received during this visit?
Very Satisfied Satisfied Somewhat Satisfied Dissatisfied Very dissatisfied

21. How satisfied were you with the time the provider spent with you?
Very Satisfied Satisfied Somewhat Satisfied Dissatisfied Very dissatisfied

22. How interested is your provider in you as a person?
Very interested Interested Somewhat Interested Disinterested Very disinterested

23. What is the average time it takes for your provider or nursing personnel to return phone calls?
Same day Next day Several days A week More than a week

24. Did your provider talk to you about preventative health issues and educate you as to your health risks? (smoking, weight control, diet, stress, self exams, checkups, screenings, family health history)
Always Usually Sometimes Only when I ask Never

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HOURS

25. Did our extended and weekend hours influence your decision to select our office as your health care provider?
Very much Somewhat Not at all

26. What are the most convenient office hours for you?
Early Morning (7 a.m. to 9 a.m.) Regular days (9 a.m. to 5 p.m.) Early evening (5 p.m. to 8 p.m.) Late evening (8 p.m. to midnight)

27. How easy or difficult was it to reach the doctor-on-call after hours or weekends?
Very easy Somewhat easy Somewhat difficult Very difficult Gave-up

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COST OF SERVICES


28. Do you feel our fees are:
High Average Low Don’t know

29. How familiar are you with our credit and billing policies?
Very familiar Somewhat familiar Somewhat unfamiliar Very unfamiliar

30. How would you rate our credit and billing policies?
Very fair Somewhat fair Fair Somewhat unfair Very unfair It should be free

31. How would you rate our office in assisting you with a problem with your insurance company?
Very helpful Somewhat helpful Helpful Somewhat unhelpful Not at all helpful

32. How would you rate the cost of care at a hospital emergency room, InstaCare®, urgent care facility compared to our costs?
Much higher Somewhat higher The same Somewhat less Much less

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SCHEDULING

33. How easy or difficult is it to get an appointment for a non-urgent problem? (physical, pap smear, screening tests)
Very easy Easy Somewhat easy Difficult Very difficult

34. How easy or difficult is it to get an appointment for an URGENT problem? (sudden illness or injury)
Very easy Easy Somewhat easy Difficult Very difficult

35. If your regular provider is unavailable, how satisfied are you when you must see another provider in the office?
Very Satisfied Satisfied Somewhat Satisfied Dissatisfied Very dissatisfied

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Reason:


Name of a support staff member in our office whom you would like to see receive special recognition:

Reason


Are there any changes or improvements you would like to see us make in the office?