Patient Survey Form
*
Patient Name
Answer
*
Doctor Name
Answer
E-mail Address
Answer
Gender
Choose one of the following answers
Male
Female
How long have you been going to your healthcare provider?
Choose one of the following answers
At least 3 months but 6 months
At least 6 months but less than 1 year
At least 2 year but less than 5 years
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?
Choose one of the following answers
Never
Sometimes
Usually
Always
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?
Choose one of the following answers
Never
Sometimes
Usually
Always
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?
Choose one of the following answers
Never
Sometimes
Usually
Always
How long has it been since your most recent visit with your healthcare provider?
Choose one of the following answers
Less than 1 month
At least 1 month but less than 3 months
At least 3 months but less than 6 months
At least 6 months but less than 12 months
12 months or more
During your most recent visit, did your healthcare provider explain things in a way that was easy to understand?
Choose one of the following answers
Yes, definitely
Yes, somewhat
No
During your most recent visit, did your healthcare provider listen carefully to you?
Choose one of the following answers
Yes, definitely
Yes, somewhat
No
During your most recent visit, did your healthcare provider seem to know the important information about your medical history?
Choose one of the following answers
Yes, definitely
Yes, somewhat
No
During your most recent visit, did your healthcare provider spend enough time with you?
Choose one of the following answers
Yes, definitely
Yes, somewhat
No
Did someone from your healthcare provider’s office follow up to give you those results?
Choose one of the following answers
Yes
No
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?
Choose one of the following answers
Yes, definitely
Yes, somewhat
No
During your most recent visit, were clerks and receptionists at your healthcare provider’s office as helpful as you thought they should be?
Choose one of the following answers
Yes, definitely
Yes, somewhat
No
During your most recent visit, did clerks and receptionists at your healthcare provider’s office treat you with courtesy and respect?
Choose one of the following answers
Yes, definitely
Yes, somewhat
No
In general, how would you rate your overall health?
Choose one of the following answers
Excellent
Very Good
Good
Fair
Poor
Submit