Patient Satisfaction Survey



 

First Name
Last
Was the reception staff professional and courteous during registration:    5- Great
   4-Good
   3-OK
   2-Fair
   1-Poor
How was the speed and efficiency of check in:    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
How was the waiting time in waiting room:    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
How was the wait time in exam room:    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
How was the wait time while waiting for your test to be performed:    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
How was the wait time for test results:    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Did your physician listen to your concerns?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Did your physician spend enough time with you?    5-Great
   4-Good
   3- OK
   2-Fair
   1-Poor
Did your physician explain to you what you wanted to know?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Did your physician give you good advice and treatment?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Were the nursing staff friendly and helpful to you?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
How was the skill of the nurse starting the IV?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Did the nursing staff answer your questions?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Was the nursing staff concern about your comfort?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Did the nursing staff show courtesy towards your family members?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Did the nursing staff provide you with adequate discharge instructions?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
How was your level of comfort during the procedure?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
How was your level of comfort 24 hours after the procedure?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Was our facility neat and clean?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Was our facility easy to find?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Did you and your family members feel comfortable and safe in our facility?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Did our staff discuss your medical information in a private manner?    5-Great
   4-Good
   3-OK
   2-Fair
   1-Poor
Will you refer our facility to your friends and relatives?    Yes
   No
What did you like the best about our center?
What did you like the least about our center?
Do you have any suggestions for improvement?
How did you hear about us?    Television
   Internet
   Newspaper
   Friend/Family
   Other
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