Our primary goal is to provide you with the best health care and service that we can. Please take a few moments to fill out this patient satisfaction survey so we can better meet your needs and fulfill your expectations.


All responses will be completely confidential - you are not asked to identify yourself on this survey.


Your participation is greatly appreciated!



1) The staff's helpfulness in scheduling my appointment was:
2) The convenience of office hours was:
3) The staff's courtesy was:
4) The staff's promptness and efficiency were:
5) The length of time, if any, that I had to wait past my appointment time was:
6) The nurse/medial assistant's skill when taking my blood sample, blood pressure, weight, temperature, etc was:
7) The nurse/medial assistant's care was:
8) The length of time I had to wait in the examination room before I saw the doctor was:
9) The doctor's interest in my overall health was:
10) The doctor's thoroughness in examining me was:
11) The doctor's explanation of my diagnosis:
12) The clarity and thoroughness of the doctor's discussion with me about treatment options were:
13) The doctor's encouragement to call if I had any problems or questions was:
14) The length of time my doctor spent with me was:
15) The staff's help with scheduling any follow-up visits, referrals, or tests was:
16) The staff's explanation of billing and payment/insurance issues was:
17) The staff's respect for my privacy was:
18) The doctor's ability to meet my needs was:
19) My overall satisfaction with the quality of care I received during this visit was:
20) My willingness to recommend this physician and practice to a close friend or family member is:
Health Status  
21) Overall, my health is:
22) The primary reason for my visit was:
regular check up, exam, or physical
get help for a specific, acute problem or illness (cold, flu, infection, etc)
for chronic disease management (asthma, diabetes, etc)
23) Insurance:
24) Age:
Under 18
Over 65
25) Gender:
26) Education:
high school, GED, or less
technical school, Associate's degree, or some college course work
Bachelor's degree
professional or graduate degree



If you have any questions or problem with this form, feel free to contact us. Thank you!

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