Patient Satisfaction with Clinical Care Survey (FSRG 21)
In order to provide you with the best care, we need to know what you think about the care you have received today. For this form 'tele-medicine' refers to all care where the patient and doctor are not in the same physical place. 'In-person' means both the patient and doctor in the same place. 'Doctor' is used generally for anyone seeing a patient. If you did not have a tele-medicine consultation, please skip those questions. Technology is used in both in-person and tele-medicine consultations, however. Please read and consider each question carefully. Your answers are confidential and will not Influence care you receive. Thank you for your time and effort in helping us improve our care.
Date of Service: *
Your answer
Type of Consultation: *
How long did you have to wait to see this provider? *
Minutes/Hours
Your answer
How long did the visit last? *
Minutes/Hours
Your answer
1. Had you heard of tele-medicine before today? *
2. Have you had any tele-medicine care before today? *
Please indicate how much you agree or disagree with each of the statements below.
Strongly Disagree, Disagree, Neurtal, Agree, Strongly Agree
3. I feel the doctor was easy to talk to. *
4. I would be happy to have technology used. *
5. I was put off by technology used. *
6. I would prefer in person consultation. *
7. I was comfortable receiving care by telemedicine today.
8. I feel my time with the doctor was private. *
9. I think the quality of medical care given through tele-medicine is at least as good as in person. *
10. Overall, I was satisfied with the visit. *
11. Tele-medicine is of value to me and my community. *
12. I felt the doctor cared about my problem. *
13. Explanation of what is being done for my problem(s) was understandable to me. *
14. My medical care needs are being/were met. *
15. Overall quality of care provided was high. *
16. I was happy with the ability to talk freely over telemedicine.
17. I was comfortable the doctor was able to understand my problem. *
18. I felt the doctor was courteous. *
19. I felt the doctor knew what he was talking about and could do it. *
20. My overall consultation experience was excellent. *
21. It was important I receive a consultation to-day. *
22. Tele-medicine made it easier for me to be seen today.
23. I would recommend tele-medicine to another person. *
24. I had at least as much time with the specialist via tele-medicine as I could have expected in person.
25. If tele-medicine were not available, I don't know if would/could have travelled to be seen at FSRG.
26. After hours appointments are important to me. *
27. I wish I had more time with the doctor and less or no time being seen by a student.
28. I was not comfortable being seen by a student.
29. The availability of this tele-medicine consultation saved me (circle all that apply)
30. Please write any additional comments and suggestions below.
If you wish to be contacted by the Ethics Chief or other Officer for additional confidential comment, please give your name and contact information, along with best time to reach you.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service