[Healthcare facility name] [Street Address] [City, ST ZIP Code] [Phone]

How Are We Doing?

Please take a few minutes to fill out this survey on the timeliness and quality of the service you received today. [Healthcare facility name] welcomes your feedback and your answers will be kept confidential. Thank you for your participation.

General Patient Information

In general, what is the quality of your health?

Outstanding	Good	Some chronic issues	Poor

How would you rate our concern for your privacy?

Outstanding	Good	Adequate

Needs improvement	Poor	N/A

How often have you visited [Healthcare facility name] within the past year?

First Visit	2-5 Visits	More than 6

Scheduling Your Appointment

Did you schedule an appointment by phone or did you drop in?

Scheduled by phone	Dropped in

How easy was it to make an appointment by telephone?

Outstanding	Very difficult

How long did you wait to speak to a scheduling staff member?

0 to 2 minutes	3 to 5 minutes	5 to 7 minutes	Longer

Was the person who scheduled your appointment courteous and helpful?

Very courteous	Rude

If you scheduled an appointment, was your appointment date later than you expected?

Yes | No

If you were seeking a referral to a specialist, was your request handled in a timely manner?

Yes | No

Day of Your Appointment

How would you rate the courtesy of the staff at the reception desk?

Very courteous	Rude

How long did you wait in the reception area beyond your scheduled appointment time?

0 to 5 minutes	5 to 20 minutes	20 to 40 minutes	Other

How long did you wait in the exam room before the physician appeared?

0 to 5 minutes	5 to 20 minutes	20 to 40 minutes	Other

Which department(s) did you visit during your appointment?

General Practitioner	Walk-in/Urgent Care	Pediatrics

Women’s Health	Counseling & Therapy	Lab

The Nursing Staff

How would you rate the competence of the nurse who helped you?

Outstanding	Good	Adequate

Needs improvement	Poor	N/A

How would characterize the concern that the nurse showed for your problem?

Outstanding	Good	Adequate

Needs improvement	Poor	N/A

Did the nurse respond to your requests within a reasonable period?

Yes | No

The Doctor

Were you able to see the doctor of your choice?

Yes | No | N/A

Did you feel that your doctor spent an adequate amount of time with you?

Yes | No | N/A

Mark the boxes that characterize the demeanor of your doctor:

Attentive	Concerned	Friendly

Distracted	Rushed	Inconsiderate

How would you rate the competence of your doctor?

Outstanding	Good	Adequate

Needs improvement	Poor	N/A

Did you feel that your doctor’s examination was thorough?

Yes | No | N/A

Please rate the clarity of the doctor’s explanation of your condition and treatment options:

Outstanding	Good	Adequate

Needs improvement	Poor	N/A

How well did your doctor include you in healthcare decisions?

Outstanding	Good	Adequate

Needs improvement	Poor	N/A

Were your questions answered to your satisfaction?

Yes | No | N/A

Would you recommend this facility and its staff to your family and friends?

Yes | No | N/A

The Lab Staff

How would you rate the professionalism and competence of the person who took your blood and worked on your lab exam?

Outstanding	Good	Adequate

Needs improvement	Poor	N/A

If you received a lab exam, please indicate the type(s) of lab exam you received:

Blood test	Breast exam	CT scan
MRI	X-ray	Other

If you received a lab exam, was the service prompt, comfortable, and courteous?

Outstanding	Good	Adequate

Needs improvement	Poor	N/A

Additional Feedback

Please list any areas in which our service could be improved.

Please share any additional comments.

Personal Information

Providing the following information is optional.

First Name	Last Name	Gender	Age
Address	City	State	ZIP Code
Email	Phone

Would you like someone to contact you regarding your responses on this survey?

Yes | No

Thank you for taking the time to fill out our survey. We rely on your feedback to help us improve our services. Your input is greatly appreciated.