Patient Survey Form


* Patient Name

* Doctor Name

E-mail Address 

Gender
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How long have you been going to your healthcare provider?
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In the last 6 months, when you phoned your healthcare provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
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In the last 6 months, when you phoned your healthcare provider’s office during regular office hours, how often did you get an answer to your medical question that same day?
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Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see your healthcare provider within 15 minutes of your appointment time?
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How long has it been since your most recent visit with your healthcare provider?
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During your most recent visit, did your healthcare provider explain things in a way that was easy to understand?
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During your most recent visit, did your healthcare provider listen carefully to you?
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During your most recent visit, did your healthcare provider seem to know the important information about your medical history?
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During your most recent visit, did your healthcare provider spend enough time with you?
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Did someone from your healthcare provider’s office follow up to give you those results?
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Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate your healthcare provider?
  1 2 3 4 5 6 7 8 9 10
10 Best provider possible - 1 Worst provider possible
Would you recommend your healthcare provider’s office to your family and friends?
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During your most recent visit, were clerks and receptionists at your healthcare provider’s office as helpful as you thought they should be?
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During your most recent visit, did clerks and receptionists at your healthcare provider’s office treat you with courtesy and respect?
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In general, how would you rate your overall health?
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