Patient Satisfaction Survey

Date Of Visit:
Month     Day     Year  
Patients Name:
 
Convenience of the office location:
   Poor      Fair      Average      Very Good      Excellent
Convenience of the contacting office by phone:
  Poor     Fair     Average     Very Good     Excellent
Adequacy of parking area:
  Poor     Fair     Average     Very Good     Excellent
Appearance, cleanliness of our facility:
  Poor     Fair     Average     Very Good     Excellent
Time spent with doctor:
  Poor     Fair     Average     Very Good     Excellent
Your understanding of what your doctor told you
  Poor     Fair     Average     Very Good     Excellent
Your doctor's ability to deal with your problem
(thoroughness, carefulness, competence):
  Poor     Fair     Average     Very Good     Excellent
Your doctor's personal manner
(courtesy, respect, sensitivity, friendliness):
   Poor     Fair     Average     Very Good     Excellent
The visit overall:
   Poor     Fair     Average     Very Good     Excellent
 
Please rate the courtesy of our staff during your visit:
Telephone Staff
   Poor     Fair     Average     Very Good     Excellent
Front Desk Staff
   Poor     Fair     Average     Very Good     Excellent
X-Ray Staff
   Poor     Fair     Average     Very Good     Excellent
Doctor's Secretary:
  Poor     Fair     Average     Very Good     Excellent
Billing Staff:
  Poor     Fair     Average     Very Good     Excellent
Which physician cared for you?
How long did it take you to get an appointment:
  1 Week      2 Weeks      3 Weeks      4 Weeks     Over 4 Weeks
Where were you seen?
How long did you wait in the waiting room?
  0-10 Minutes      10-20 Minutes      20-30 Minutes      Over 30 Minutes
How long did you wait in the exam room?
  0-10 Minutes      10-20 Minutes      20-30 Minutes      Over 30 Minutes
What type of visit were you seen for?
Injury 
First visit following surgery
Follow-up visit for a continuing problem
Over 30 Minutes
How did you learn about our practice?
Physician Referral  Other health care professional recommendation  Employer Referral
Attorney Recommendation  Referred from emergency room  Phone Book  Website
Family or Friendk  Locations  Radio  TV  Newspaper
Did you receive froms to complete from our office before your visit?
Yes   No
Did you receive statements from our billing office?
Yes   No
If so, were they easy to understand?
Yes   No
Would you recommend this practice to family and friends?
Yes   No
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