Piedmont Health: Patient Satisfaction Survey
Please take a few minutes to complete this survey. We want to know how you feel about the care you received at our health center. Your feedback is important to us.
Choose Location *
Please Type In Name of Provider Seen *
Your answer
About the Patient
What is your age?
What is your gender?
Do you consider yourself Hispanic or Latino?
What is your race?
Ease of Getting Care
Mark one answer only. Response Definition: 4=Excellent 3=Good 2=Fair 1=Poor
Able to get appointment for checkups (yearly exams, well-visits, regular follow-up visits)
Able to make same day appointment when sick or hurt
Health center hours work for me
Phone calls get through easily
I get called back quickly
Able to get medical advice when the office is closed
Rate the value of care you received at PHS
Length of waiting time at the clinic
Facility
Mark one answer only. Response Definition: 4=Excellent 3=Good 2=Fair 1=Poor
Easy to Find Clinic
Lobby and waiting room was comfortable and clean
Exam room was comfortable and clean
Handicap accessibility
Front Desk
Mark one answer only. Response Definition: 4=Excellent 3=Good 2=Fair 1=Poor
Friendly and helpful to you
Nurses, Medical Assistants or Dental Assistants
Mark one answer only. Response Definition: 4=Excellent 3=Good 2=Fair 1=Poor
Listens and answers to your questions
Friendly and helpful to you
Provider(s) - The person who took care of you
Mark one answer only. Response Definition: 4=Excellent 3=Good 2=Fair 1=Poor
Listens to and answers your questions
Spends enough time with you
Friendly and helpful to you
Gives you information you can understand
Considers your personal and family beliefs
Involves other doctors and caregivers in your care when needed
Gives you good advice and treatment
Pharmacy Staff
Mark one answer only. Response Definition: 4=Excellent 3=Good 2=Fair 1=Poor
Friendly and helpful to you
Discusses your medication with you
General
Mark one answer only. Reponse Definition: Y = Yes, N = No, NA = Not Applicable
Have you ever been given information on what it means to have a "medical home" or a "dental home"?
Do you feel that we are your medical/dental home?
If you may need other services that we do not provide, did we help you find those services that you need?
If you have been referred to a specialist or a community resource, did you find them to be helpful?
Would you send your friends and family to us?
Experience with Today's Visit
Mark one answer only. Reponse Definition: Y = Yes, N = No, NA = Not Applicable
Did someone talk to you today about your health goals?
Were you asked today if you had visits with other healthcare providers since your last visit with us?
Were you helped today with making appointments to see other providers or for specialty care?
Comments
What one thing could we do to make your visits with us better? Please provide any additional feedback?
Your answer
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