Skip to content
Patient Experience Survey
**On a scale of 1 to 5, with 5 being the easiest / best, please rate us!**
*
1.
What department were you
specifically
visiting and giving feedback on today?
(Required.)
Podiatry
Optometry
Physical Therapy
Lab / X-ray
Medical
Dental
Pharmacy
Chemical Dependency
Mental Health
Human Resources
Transportation
WIC
Dietician at Public Health
Fitness / Wellness Class
Diabetes
Senior Center
Registration / Eligibility Coordinators - Business Office
Purchased Referred Care - Business Office
Referral Coordinator - Business Office
Public Health
Administration
Other (please specify)
2.
How easy was it to schedule an appointment with
this department
?
1
2
3
4
5
Not applicable / No appointment needed
3.
How long did you wait, beyond your appointment time, to be seen by the service provider?
Less than 10 minutes
10 to 20 minutes
20 to 30 minutes
More than 30 minutes
4.
How would you rate the overall care you received today from this provider (doctor, dentist, pharmacist, mental health therapist, transporter, etc.)?
1
2
3
4
5
Not applicable / no provider
5.
How would you rate the overall care you received from check-in until you left
this department
?
1
2
3
4
5
6.
Were your questions answered in an easy to understand manner by
this department
?
Yes
No
7.
Did you leave
this department
today with an understanding of any follow up (appointments, referrals, etc.) that need to happen?
Yes
No
8.
After contacting Yellowhawk for this need, how quick did you receive an appointment or service?
Within the timeframe I needed / requested it.
Within a week.
Within two weeks or less.
More than two weeks after requesting.
9.
When was the last time you visited
this
department
?
Less than a year
1-3 years
3-5 years
Greater than 5 years
10.
During
this
visit, did you feel you experienced any form of discrimination or did you feel staff expressed personal bias?
No
Yes
If yes, please specify.
11.
What barriers do you experience in keeping your appointments?
Not Applicable (N/A)
Transportation
Economics
Planning / Time
Work / School
Other (please specify)
12.
How likely are you to recommend Yellowhawk
to a friend or family member?
1
2
3
4
5
13.
What do you like
the most
about Yellowhawk and your visit today?
(Please be specific and check all that apply
)
Easy appointment availability
Cleanliness of facility
Friendly staff
Customer service
Accessibility (location of facility)
Provider knowledge
My provider / counselor
Safety (personal)
Other (please specify)
14.
What do you like
the least
about Yellowhawk and your visit today? Any suggestions on how we can improve? (
Please be specific and check all that apply
)
Nothing. My visit met my needs today.
Appointment availability
Accessibility (location)
Customer service
Provider knowledge
Cleanliness of facility
My provider / counselor
Safety (personal)
Suggestions
Current Progress,
0 of 14 answered
