|
Poor |
Fair |
Good |
Very
Good |
Excellent |
| 1.
How long you waited to get an appointment |
O |
O |
O |
O |
O |
| 2.
Convenience of the location of the office |
O |
O |
O |
O |
O |
| 3.
Getting through to the office by phone |
O |
O |
O |
O |
O |
| 4.
Length of time waiting at the office |
O |
O |
O |
O |
O |
| 5.
Time spent with the physician/health care professional you
saw |
O |
O |
O |
O |
O |
| 6.
Explanation of what was done for you |
O |
O |
O |
O |
O |
| 7.
Technical skills (thoroughness, carefulness, competence)
of the physician/health care professional you saw |
O |
O |
O |
O |
O |
| 8.
The personal manner (courtesy, respect, sensitivity,
friendliness) of: |
O |
O |
O |
O |
O |
|
a. The physician/health care professional you saw |
O |
O |
O |
O |
O |
|
b. The nursing staff |
O |
O |
O |
O |
O |
|
c. The reception staff |
O |
O |
O |
O |
O |
| 9.
The visit overall |
O |
O |
O |
O |
O |
| 10.
In general, would you say your health is |
O |
O |
O |
O |
O |
|
Definitely
not |
Probably
not |
Probably
yes |
Definitely
yes |
|
| 11.
Would you recommend the physician/health care professional
you saw to your family and friends? |
O |
O |
O |
O |
|
| |
Male |
Female |
|
|
|
| 12.
Are you (patient) male or female? |
O |
O |
|
|
|
| 13.
How old were you (patient) on your last birthday? |
__
__ __ Years |
Example:
__ 7 2 Years |
|
