Healthcare: Patient Satisfaction Survey Long
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Dear Patient:

We are interested in finding out how your feel about various aspects of our office practice. Please take a minute to complete this questionnaire about your visit to our office today. Your responses are confidential and are greatly appreciated. Thank you.
Q1. Name of the doctor this survey is about:
Q2. Please rate each of the following:
A. The convenience of the office location. (Consider travel time, access by public transportation, and parking.)
B. The accessibility of the office. (Is the office easy to find, are stairs or elevators readily available, is handicapped entrance adequate, etc.)
C. The comfort of the reception area.
D. The attractiveness of the reception area.
E. The comfort of the examining room(s).
F. The cleanliness of the office, including the reception area and examination room.
G. The promptness with which our telephones are answered.
H. The courtesy of the staff.
I. The amount of time spent with your physician.
J. The communication with your physician.
K. The quality of the care you received.
L. The privacy of the physician?s consultation room and the examination room.
M. Overall, how would you rate your experience?
Q3. How caring would you say the following individuals are?
Extremely Uncaring
Very Uncaring
Very Caring
Extremely Caring
Your doctor?
Your medical staff?
Our office staff?
Q4. Would your recommend your doctor to your family or friends?
These questions pertain to the patient to whom this survey was addressed:
Q5. Age in years:
Q6. Gender:
Q7. How long have you been a patient of this doctor?
Q8. How many times have you visited this doctor?s office in the past 12 months for medical care?
Q9. Comments
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