1. Your evaluation of the receptionist:                                  Poor Average Excellent

2. Your evaluation of the nurses:                                          Poor Average Excellent

3. Your evaluation of the physician assistant                  Poor Average Excellent

4. Your evaluation of the physician:                                      Poor Average Excellent

5. Your evaluation of the medical billing staff member:   Poor Average Excellent

6. How well your medical questions were answered:      Poor Average Excellent

7. The comfort of the office:                                                    Poor Average Excellent

8. The appearance of the office:                                            Poor Average Excellent

9. The amount of time the staff spent with you:                  Poor Average Excellent

10. The amount of time the physician assistant spent: Poor Average Excellent

11. Physician assistant was courteous:                           Poor Average Excellent

12. Physician assistant was friendly:                                Poor Average Excellent

13. Physician assistant's ability to answer questions:   Poor Average Excellent

14. Physician assistant's medical professional skills:  Poor Average Excellent

15. The amount of time the physician spent with you:      Poor Average Excellent

16. The value of any written information you received:      Poor Average Excellent

17. Please indicate the areas in which this office can improve:

Better magazines in the reception area
            Titles I would like:
Friendlier staff
More information on my condition
Less waiting time
More concern from the doctor
Better parking
More time with the doctor
Other:

18. About how long did you have to wait in the reception area today? 

19. How do you feel about the waiting time in this office?
It is much too long.
It is a little too long.
It is acceptable.

20. How likely are you to refer your friends and neighbors to this office?
The care is excellent! I will refer everyone I can to this office.
The care is good. I will tell friends about the office only if they ask me.
The care is deficient. I will tell friends not to come to this office.

21. Please select the appropriate age group:
19 years old or younger
Between 20 and 44 years old
Between 45 and 64 years old
Over 65 years old

22. How did you find out about this office?
I was referred here by a medical doctor.
I was referred here by a friend or family member.
I was referred here by the emergency room at the hospital.
I found this doctor in my medical plan's provider listing.
I was referred by a chiropractor.
Other:

Your comments and suggestions are the most important part of this survey. Please take a moment to share any other comments you may have:

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