Patient Satisfaction Survey

          Quality Management Consultants, Inc.



          1. I came to Dr. ____________ office for care because (check each one that applies):
          • ¨ My primary physician is here
          • ¨ I have no other health care provider
          • ¨ I was referred by another doctor, hospital or clinic
          • ¨ Convenience
          • ¨ It was easy to get an appointment
          • ¨ Affordable
          • ¨ I needed the type of care that this doctor provides

          2. I am here today for:
          • ¨ A physical or check up (not ill)
          • ¨ Treatment of an illness or condition

          3. How long did you have to wait before you were seen by Dr. ?
          • ¨ Less than 10 minutes
          • ¨ 10 to 20 minutes
          • ¨ 20 to 30 minutes
          • ¨ More than 30 minutes
          4. Was the office staff pleasant to you on the telephone?
          • Yes
          • No

          5. Is the cost of the clinic visit reasonable?
          • Yes
          • No

          6. Are the clinic hours convenient for you?
          • Yes
          • No

          7. Are the clinic hours convenient for your family?
          • Yes
          • No

          8. Did the care you received address your problem to your satisfaction?
          • Yes
          • No

          If you answered no, please state why not.



          9. How satisfied are you with the information you received from the clinic staff about your condition?
          • Very satisfied
          • Satisfied
          • Not satisfied
          • No opinion

          10. How satisfied are you with the information you received from the doctor?
          • Very satisfied
          • Satisfied
          • Not satisfied
          • No opinion

          11. Overall, how satisfied are you with your visit today?
          • Very satisfied
          • Satisfied
          • Not satisfied
          • No opinion

          12. Will you return to the doctor's office?
          • Yes
          • No
          11. Additional comments

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