Backround Information

Gender

• Male
• Female
• Rather Not Say

Age

• Less than 18
• 18-34
• 35-54
• 55-64
• 65 or Older

Date of Visit:

Name of Provider:

Please check the box that best describes your experience

Access To Care

1. Time required to to schedule an appointment with your doctor

• Highly Dissatisfied
• Somewhat Dissatisfied
• Somewhat Satisfied
• Highly Satisfied

2. Overall helpfulness of staff

• Highly Dissatisfied
• Somewhat Dissatisfied
• Somewhat Satisfied
• Highly Satisfied

Your Office Experience

1. Amount of time spent in waiting room before taken to exam room

• Highly Dissatisfied
• Somewhat Dissatisfied
• Somewhat Satisfied
• Highly Satisfied

2. Thoroughness of doctor's exam

• Highly Dissatisfied
• Somewhat Dissatisfied
• Somewhat Satisfied
• Highly Satisfied

3. Overall satisfaction with my visit

• Highly Dissatisfied
• Somewhat Dissatisfied
• Somewhat Satisfied
• Highly Satisfied

Please feel free to add any additional comments

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