Patient Satisfaction Survey

To our Patients:
We are interested in receiving your feedback about the care provided at our office. Please take a few minutes to complete this survey and return in to us. Your responses are important to us.

How satisfied are you with the following?

   Extremely Dissatisfied   Very Dissatisfied   Satisfied   Very Satisfied   Extremely Satisfied 
1. Ease of making appointments for checkups
(physical exams, well visits, routine follow-up appointments) ?
2. Ease of making appointments for sickness ?
3. Ease in contacting your doctor when our office is closed ?
4. Ease in speaking directly with your doctor by telephone when you call during office hours ?
5. The time it takes someone from our office to respond when you call during office hours ?
6. Waiting time in our office ?
7. Ease in obtaining follow-up information and care
(test results, medicines, care instruction) ?
8. Overall medical care at your doctor's office ?
9. Our office's appearance ?
10.  Our office's convenience (location, parking, hours, office layout) ?
11. The way we teach you about improving your health ?
12. The way your doctor involves other doctors and caregivers in your care when needed ?
13. How caring is your doctor ?
14. How caring is our medical staff ?
15. How caring is our office staff ?
  Definitely
would not		 Probably
would not		 Not
sure		 Probably
would		 Definitely
would
16. Would you recommend your doctor to your family or friends ?

Please tell us:
(Reminder: These questions pertain to the patient to whom this survey was addressed - with the exception of 19, 20 and 21 which are for the responsible party.)


17. Your age in years:  Less than 1  10-19  40-49  66-75
   1-4  20-29  50-59  More than 75
   5-9  30-39  60-65

18. Your name: 


19. Your gender:    Male    Female


20.The name of your health plan: 


21. The name of your employer: 


22. Please check your level of education:  8th Grade or Less  Some College
   Some High School  College Graduate
   High School Graduate/td>  Post-Graduate Degree

23. How long have you been a patient with this doctor?    Less than 1 yr    1-4yrs   5-9yrs   10 yrs or more


24. How many times have you visited this doctor's office in the past 12 months for medical care?
 0    1    2    3    4    5    6 or more  


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