Patient Satisfaction Survey
What Provider did you see today? *
CALLING THE CLINIC/SCHEDULING APPOINTMENTS
A) Phone instructions were easy to follow
Strongly Disagree
Strongly Agree
B) My phone call was answered in a timely way
Strongly Disagree
Strongly Agree
C) If I left a message, my phone call was returned in a timely way
Call Center
Strongly Disagree
Strongly Agree
Front Desk
Strongly Disagree
Strongly Agree
Nurses
Strongly Disagree
Strongly Agree
D) Call Center provided good customer service
Strongly Disagree
Strongly Agree
E) I was satisfied with the date and time of my appointment
Strongly Disagree
Strongly Agree
CHECKING IN FOR MY APPOINTMENT
1) The lobby was clean and welcoming
Strongly Disagree
Strongly Agree
2) The reception staff was friendly and respectful
Strongly Disagree
Strongly Agree
3) I was satisfied with waiting time in the lobby
Strongly Disagree
Strongly Agree
MY APPOINTMENT
1) I was satisfied with waiting time in the exam room
Strongly Disagree
Strongly Agree
2) About the Medical Assistant
A) Was friendly and respectful
Strongly Disagree
Strongly Agree
B) Had appropriate skills and abilities
Strongly Disagree
Strongly Agree
C) Gave clear instructions
Strongly Disagree
Strongly Agree
3) About the Nurse
A) Was friendly and respectful
Strongly Disagree
Strongly Agree
B) Had appropriate skills and abilities
Strongly Disagree
Strongly Agree
C) Gave clear instructions
Strongly Disagree
Strongly Agree
D) Gave helpful heath education/self-care handouts
Strongly Disagree
Strongly Agree
4) About the Provider
A) Was friendly and respectful
Strongly Disagree
Strongly Agree
B) Had appropriate skills and abilities
Strongly Disagree
Strongly Agree
C) Spent time with me during my visit
Strongly Disagree
Strongly Agree
D) Listened carefully to my concerns
Strongly Disagree
Strongly Agree
E) Explained things in a way I could understand
Strongly Disagree
Strongly Agree
THE CLINIC
1) I am satisfied with my overall experience at the Clinic
Strongly Disagree
Strongly Agree
2) I would recommend Community Clinic to others
Strongly Disagree
Strongly Agree
SOME INFORMATION ABOUT YOU
Where have you received medical care in the past 3 years?
How many times have you been to Community Clinic in the past year?
Have you ever put off health care because of the cost?
Submit
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