What is your relationship to this office?

Are you able to get to your appointments when you choose?

In the last 12 months how often did you have to see someone else when you wanted to see your personal doctor or nurse?

Is there anything our practice can do to improve the care and services for you?

"I am delighted with everything about this practice because my expectations for service and quality of care are exceeded."

How long you waited to get an appointment?

Convenience of the locaiton of the office?

Getting through to the office by phone?

Length of time waiting at the office?

Amount of time spent with the person you saw?

Explanation about your health problems and medical treatment?

Explanation about what you can do to improve your health?

Information provided about other resources (reading materials, support groups)?

The skills (thoroughness, carefullness, competence) of the person you saw?

The personal manner (courtesy, respect, friendliness) of the person you saw?

How would you rate your satisfaction with getting the help you needed?

How do you feel about the quality of the visit overall?

In general how would you rate your overall health?

What is your age?

Are you male or female?

Is this practice your usual provider of care?

Would you recommend our office to others?

Did anyone provide you with outstanding service?

I was especially pleased with:

You need to improve:

My name is

Daytime phone number

My email address is

Please contact me