Patient Survey Question Title * 1. When did you come in for an appointment? Date/Time Date Time AM/PM - AM PM Question Title * 2. What was the purpose of your visit? Well care Sick visit Bloodwork/vaccines Weight Check Telehealth Question Title * 3. Which provider did you see? Dr. Richter Dr. Hamlet Dr. Wang Other (ie Nurse visit) Question Title * 4. Evaluate the following statements regarding booking your appointment with Hudson Heights Pediatrics. Strongly Disagree Disagree Neither Disagree Nor Agree Agree Strongly Agree It was easy to get through on our phone lines to schedule an appointment. It was easy to get through on our phone lines to schedule an appointment. Strongly Disagree It was easy to get through on our phone lines to schedule an appointment. Disagree It was easy to get through on our phone lines to schedule an appointment. Neither Disagree Nor Agree It was easy to get through on our phone lines to schedule an appointment. Agree It was easy to get through on our phone lines to schedule an appointment. Strongly Agree I was able to make a well visit appointment for a date and time that was reasonable and convenient for me. I was able to make a well visit appointment for a date and time that was reasonable and convenient for me. Strongly Disagree I was able to make a well visit appointment for a date and time that was reasonable and convenient for me. Disagree I was able to make a well visit appointment for a date and time that was reasonable and convenient for me. Neither Disagree Nor Agree I was able to make a well visit appointment for a date and time that was reasonable and convenient for me. Agree I was able to make a well visit appointment for a date and time that was reasonable and convenient for me. Strongly Agree I was able to schedule a sick visit appointment for my child in a timely fashion. I was able to schedule a sick visit appointment for my child in a timely fashion. Strongly Disagree I was able to schedule a sick visit appointment for my child in a timely fashion. Disagree I was able to schedule a sick visit appointment for my child in a timely fashion. Neither Disagree Nor Agree I was able to schedule a sick visit appointment for my child in a timely fashion. Agree I was able to schedule a sick visit appointment for my child in a timely fashion. Strongly Agree Additional Comments Question Title * 5. Upon arriving in our office: Strongly Disagree Disagree Neither Disagree Nor Agree Agree Strongly Agree Our staff was friendly and courteous to you and your child. Our staff was friendly and courteous to you and your child. Strongly Disagree Our staff was friendly and courteous to you and your child. Disagree Our staff was friendly and courteous to you and your child. Neither Disagree Nor Agree Our staff was friendly and courteous to you and your child. Agree Our staff was friendly and courteous to you and your child. Strongly Agree The registration and waiting area was welcoming, clean and comfortable. The registration and waiting area was welcoming, clean and comfortable. Strongly Disagree The registration and waiting area was welcoming, clean and comfortable. Disagree The registration and waiting area was welcoming, clean and comfortable. Neither Disagree Nor Agree The registration and waiting area was welcoming, clean and comfortable. Agree The registration and waiting area was welcoming, clean and comfortable. Strongly Agree The examination rooms were neat and clean. The examination rooms were neat and clean. Strongly Disagree The examination rooms were neat and clean. Disagree The examination rooms were neat and clean. Neither Disagree Nor Agree The examination rooms were neat and clean. Agree The examination rooms were neat and clean. Strongly Agree Additional Comments Question Title * 6. The professional or technical skills of the following staff were thorough, personable and courteous. Strongly Disagree Disagree Neither Disagree Nor Agree Agree Strongly Agree Phone/Appointment Scheduling Phone/Appointment Scheduling Strongly Disagree Phone/Appointment Scheduling Disagree Phone/Appointment Scheduling Neither Disagree Nor Agree Phone/Appointment Scheduling Agree Phone/Appointment Scheduling Strongly Agree Receptionist Receptionist Strongly Disagree Receptionist Disagree Receptionist Neither Disagree Nor Agree Receptionist Agree Receptionist Strongly Agree Assistant who prepared my child for examination Assistant who prepared my child for examination Strongly Disagree Assistant who prepared my child for examination Disagree Assistant who prepared my child for examination Neither Disagree Nor Agree Assistant who prepared my child for examination Agree Assistant who prepared my child for examination Strongly Agree Billing Billing Strongly Disagree Billing Disagree Billing Neither Disagree Nor Agree Billing Agree Billing Strongly Agree Additional Comments Question Title * 7. Evaluate the following statements about your doctor's care for your child. Strongly Disagree Disagree Neither Disagree Nor Agree Agree Strongly Agree I trust my doctor to make medical decisions that are in my child's best interest. I trust my doctor to make medical decisions that are in my child's best interest. Strongly Disagree I trust my doctor to make medical decisions that are in my child's best interest. Disagree I trust my doctor to make medical decisions that are in my child's best interest. Neither Disagree Nor Agree I trust my doctor to make medical decisions that are in my child's best interest. Agree I trust my doctor to make medical decisions that are in my child's best interest. Strongly Agree My doctor is helpful at explaining my child's medical condition(s). My doctor is helpful at explaining my child's medical condition(s). Strongly Disagree My doctor is helpful at explaining my child's medical condition(s). Disagree My doctor is helpful at explaining my child's medical condition(s). Neither Disagree Nor Agree My doctor is helpful at explaining my child's medical condition(s). Agree My doctor is helpful at explaining my child's medical condition(s). Strongly Agree My doctor listens well to my concerns and questions. My doctor listens well to my concerns and questions. Strongly Disagree My doctor listens well to my concerns and questions. Disagree My doctor listens well to my concerns and questions. Neither Disagree Nor Agree My doctor listens well to my concerns and questions. Agree My doctor listens well to my concerns and questions. Strongly Agree Additional Comments Question Title * 8. Overall, I am satisfied with my doctor. Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied Question Title * 9. How likely are you to recommend your doctor to family or friends? Definitely would not Probably would not Probably would Definitely would Question Title * 10. Please let us know what you like best about visiting our office and if there is one thing you would like us to improve upon. Done
