Personal Physicians

Call us: (708) 652-2040

  • 5909 West 35th Street - Cicero
  • 235 Remington Blvd, Suite E - Bolingbrook
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Call us: (708) 652-2040

  • Cicero, Bolingbrook
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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:
    23. Insurance:
    24. Age:
    25. Gender:
    26. Education:


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

    Thank you!

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