PATIENT SATISFACTION QUESTIONNAIRE Name Email Address 1. How long have you been a patient here? 1. How long have you been a patient here? First visit 1 1 to 3 years 3 to 5 years Over 5 years 2. If this is your first visit, how did you hear about us? 2. If this is your first visit, how did you hear about us? Referred by another patient Referred by another physician Internet / telephone directory HMO or other insurance Other 3. How convenient are we in the following areas? Please rate on a scale of: 1 - very convenient; 2 - somewhat convenient; 3 - not convenient Location Parking: Location Parking: 1 - Very Convenient 2 - Somewhat Convenient 3 - Not Convenient Practice hours: Practice hours: 1 - Very Convenient 2 - Somewhat Convenient 3 - Not Convenient Availability of staff to help you with your questions Availability of staff to help you with your questions 1 - Very Convenient 2 - Somewhat Convenient 3 - Not Convenient Please let us know what we can do to improve any of these areas: 4. Was it easy and convenient to schedule an appointment? 4. Was it easy and convenient to schedule an appointment? YES NO If NO, Please Explain: 5. When you last telephoned the Practice, were you treated courteously by the staff? 5. When you last telephoned the Practice, were you treated courteously by the staff? YES NO If NO, Please Explain: 6. When making your last appointment, did the staff make every effort to assist with a time and day that was convenient for you? 6. When making your last appointment, did the staff make every effort to assist with a time and day that was convenient for you? YES NO If NO, Please Explain: 7. When you come into the Practice, is the staff courteous? 7. When you come into the Practice, is the staff courteous? YES NO If NO, Please Explain: 8. Are you usually seen in a prompt manner? 8. Are you usually seen in a prompt manner? YES NO If NO, Please Explain: 9. Please rate us on how genuinely interested we seem to be in you as a person 9. Please rate us on how genuinely interested we seem to be in you as a person Always concerned Sometimes indifferent Usually concerned Never seem to have enough time 10. During your Practice visits, do you think we adequately answer your questions? 10. During your Practice visits, do you think we adequately answer your questions? YES NO If NO, Please Explain: 11. Are you satisfied with the quality of medical treatment you receive from us? 11. Are you satisfied with the quality of medical treatment you receive from us? YES NO If NO, Please Explain: 12. How satisfied are you with the general appearance and clinically cleanness of our facility? 12. How satisfied are you with the general appearance and clinically cleanness of our facility? YES NO If NO, Please Explain: 13. If you waited beyond your appointment time – did someone explained why, and apologised? 13. If you waited beyond your appointment time – did someone explained why, and apologised? YES NO If NO, Please Explain: 14. If you left a message to speak to Dr regarding a patient in hospital, about medical results or possibly a prescription: Was the person courteous? 14. If you left a message to speak to Dr regarding a patient in hospital, about medical results or possibly a prescription: Was the person courteous? YES NO Did Dr phone back in reasonable time? Did Dr phone back in reasonable time? YES NO If NO, Please Explain: 15. On a scale of 1 to 5, 1 being extremely poor and 5 being excellent, how would you rate your overall experience with our Practice? 15. On a scale of 1 to 5, 1 being extremely poor and 5 being excellent, how would you rate your overall experience with our Practice? 1 2 3 4 5 16. What could we do to make the experience better? 17. If there was one thing you could change about your experience with this Practice, what would it be? Your comments are appreciated: Send
