Patient Satisfaction Survey

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.

Please rate each question on how well you think we are doing.

	Poor	Fair	Ok	Good	Great
Ability to get in to be seen.	Ability to get in to be seen. Poor	Ability to get in to be seen. Fair	Ability to get in to be seen. Ok	Ability to get in to be seen. Good	Ability to get in to be seen. Great
Hours center is open.	Hours center is open. Poor	Hours center is open. Fair	Hours center is open. Ok	Hours center is open. Good	Hours center is open. Great
Convenience of center's location.	Convenience of center's location. Poor	Convenience of center's location. Fair	Convenience of center's location. Ok	Convenience of center's location. Good	Convenience of center's location. Great
Prompt return on calls.	Prompt return on calls. Poor	Prompt return on calls. Fair	Prompt return on calls. Ok	Prompt return on calls. Good	Prompt return on calls. Great

Poor

Fair

Good

Great

Ability to get in to be seen.

Ability to get in to be seen. Poor

Ability to get in to be seen. Fair

Ability to get in to be seen. Ok

Ability to get in to be seen. Good

Ability to get in to be seen. Great

Hours center is open.

Hours center is open. Poor

Hours center is open. Fair

Hours center is open. Ok

Hours center is open. Good

Hours center is open. Great

Convenience of center's location.

Convenience of center's location. Poor

Convenience of center's location. Fair

Convenience of center's location. Ok

Convenience of center's location. Good

Convenience of center's location. Great

Prompt return on calls.

Prompt return on calls. Poor

Prompt return on calls. Fair

Prompt return on calls. Ok

Prompt return on calls. Good

Prompt return on calls. Great

	Poor	Fair	Ok	Good	Great
Time in waiting room.	Time in waiting room. Poor	Time in waiting room. Fair	Time in waiting room. Ok	Time in waiting room. Good	Time in waiting room. Great
Time in exam room.	Time in exam room. Poor	Time in exam room. Fair	Time in exam room. Ok	Time in exam room. Good	Time in exam room. Great
Waiting for tests to be performed.	Waiting for tests to be performed. Poor	Waiting for tests to be performed. Fair	Waiting for tests to be performed. Ok	Waiting for tests to be performed. Good	Waiting for tests to be performed. Great
Waiting for test results.	Waiting for test results. Poor	Waiting for test results. Fair	Waiting for test results. Ok	Waiting for test results. Good	Waiting for test results. Great

Poor

Fair

Good

Great

Time in waiting room.

Time in waiting room. Poor

Time in waiting room. Fair

Time in waiting room. Ok

Time in waiting room. Good

Time in waiting room. Great

Time in exam room.

Time in exam room. Poor

Time in exam room. Fair

Time in exam room. Ok

Time in exam room. Good

Time in exam room. Great

Waiting for tests to be performed.

Waiting for tests to be performed. Poor

Waiting for tests to be performed. Fair

Waiting for tests to be performed. Ok

Waiting for tests to be performed. Good

Waiting for tests to be performed. Great

Waiting for test results.

Waiting for test results. Poor

Waiting for test results. Fair

Waiting for test results. Ok

Waiting for test results. Good

Waiting for test results. Great

	Poor	Fair	Ok	Good	Great
Courtesy of person who scheduled your appointment.	Courtesy of person who scheduled your appointment. Poor	Courtesy of person who scheduled your appointment. Fair	Courtesy of person who scheduled your appointment. Ok	Courtesy of person who scheduled your appointment. Good	Courtesy of person who scheduled your appointment. Great
Courtesy of staff in the registration process.	Courtesy of staff in the registration process. Poor	Courtesy of staff in the registration process. Fair	Courtesy of staff in the registration process. Ok	Courtesy of staff in the registration process. Good	Courtesy of staff in the registration process. Great

Poor

Fair

Good

Great

Courtesy of person who scheduled your appointment.

Courtesy of person who scheduled your appointment. Poor

Courtesy of person who scheduled your appointment. Fair

Courtesy of person who scheduled your appointment. Ok

Courtesy of person who scheduled your appointment. Good

Courtesy of person who scheduled your appointment. Great

Courtesy of staff in the registration process.

Courtesy of staff in the registration process. Poor

Courtesy of staff in the registration process. Fair

Courtesy of staff in the registration process. Ok

Courtesy of staff in the registration process. Good

Courtesy of staff in the registration process. Great

	Poor	Fair	Ok	Good	Great
Friendliness / courtesy of the care provider.	Friendliness / courtesy of the care provider. Poor	Friendliness / courtesy of the care provider. Fair	Friendliness / courtesy of the care provider. Ok	Friendliness / courtesy of the care provider. Good	Friendliness / courtesy of the care provider. Great
Explanation care provider gave you about your problem / condition.	Explanation care provider gave you about your problem / condition. Poor	Explanation care provider gave you about your problem / condition. Fair	Explanation care provider gave you about your problem / condition. Ok	Explanation care provider gave you about your problem / condition. Good	Explanation care provider gave you about your problem / condition. Great
Information care provider gave you about medications / health conditions. (if any)	Information care provider gave you about medications / health conditions. (if any) Poor	Information care provider gave you about medications / health conditions. (if any) Fair	Information care provider gave you about medications / health conditions. (if any) Ok	Information care provider gave you about medications / health conditions. (if any) Good	Information care provider gave you about medications / health conditions. (if any) Great
Instructions the care provider gave you about follow-up. (if any)	Instructions the care provider gave you about follow-up. (if any) Poor	Instructions the care provider gave you about follow-up. (if any) Fair	Instructions the care provider gave you about follow-up. (if any) Ok	Instructions the care provider gave you about follow-up. (if any) Good	Instructions the care provider gave you about follow-up. (if any) Great
Your confidence in this care provider.	Your confidence in this care provider. Poor	Your confidence in this care provider. Fair	Your confidence in this care provider. Ok	Your confidence in this care provider. Good	Your confidence in this care provider. Great
Likelihood of you recommending this provider.	Likelihood of you recommending this provider. Poor	Likelihood of you recommending this provider. Fair	Likelihood of you recommending this provider. Ok	Likelihood of you recommending this provider. Good	Likelihood of you recommending this provider. Great

Poor

Fair

Good

Great

Friendliness / courtesy of the care provider.

Friendliness / courtesy of the care provider. Poor

Friendliness / courtesy of the care provider. Fair

Friendliness / courtesy of the care provider. Ok

Friendliness / courtesy of the care provider. Good

Friendliness / courtesy of the care provider. Great

Explanation care provider gave you about your problem / condition.

Explanation care provider gave you about your problem / condition. Poor

Explanation care provider gave you about your problem / condition. Fair

Explanation care provider gave you about your problem / condition. Ok

Explanation care provider gave you about your problem / condition. Good

Explanation care provider gave you about your problem / condition. Great

Information care provider gave you about medications / health conditions. (if any)

Information care provider gave you about medications / health conditions. (if any) Poor

Information care provider gave you about medications / health conditions. (if any) Fair

Information care provider gave you about medications / health conditions. (if any) Ok

Information care provider gave you about medications / health conditions. (if any) Good

Information care provider gave you about medications / health conditions. (if any) Great

Instructions the care provider gave you about follow-up. (if any)

Instructions the care provider gave you about follow-up. (if any) Poor

Instructions the care provider gave you about follow-up. (if any) Fair

Instructions the care provider gave you about follow-up. (if any) Ok

Instructions the care provider gave you about follow-up. (if any) Good

Instructions the care provider gave you about follow-up. (if any) Great

Your confidence in this care provider.

Your confidence in this care provider. Poor

Your confidence in this care provider. Fair

Your confidence in this care provider. Ok

Your confidence in this care provider. Good

Your confidence in this care provider. Great

Likelihood of you recommending this provider.

Likelihood of you recommending this provider. Poor

Likelihood of you recommending this provider. Fair

Likelihood of you recommending this provider. Ok

Likelihood of you recommending this provider. Good

Likelihood of you recommending this provider. Great

	Poor	Fair	Ok	Good	Great
Kim Brunson	Kim Brunson Poor	Kim Brunson Fair	Kim Brunson Ok	Kim Brunson Good	Kim Brunson Great
Lacey Brown	Lacey Brown Poor	Lacey Brown Fair	Lacey Brown Ok	Lacey Brown Good	Lacey Brown Great
Stacy Ferrell	Stacy Ferrell Poor	Stacy Ferrell Fair	Stacy Ferrell Ok	Stacy Ferrell Good	Stacy Ferrell Great
Joy Lockhartt	Joy Lockhartt Poor	Joy Lockhartt Fair	Joy Lockhartt Ok	Joy Lockhartt Good	Joy Lockhartt Great
Tiffany Freeman	Tiffany Freeman Poor	Tiffany Freeman Fair	Tiffany Freeman Ok	Tiffany Freeman Good	Tiffany Freeman Great
Lacey Russell	Lacey Russell Poor	Lacey Russell Fair	Lacey Russell Ok	Lacey Russell Good	Lacey Russell Great
Lori Cummings	Lori Cummings Poor	Lori Cummings Fair	Lori Cummings Ok	Lori Cummings Good	Lori Cummings Great
Madeline Gebhardt	Madeline Gebhardt Poor	Madeline Gebhardt Fair	Madeline Gebhardt Ok	Madeline Gebhardt Good	Madeline Gebhardt Great
TaMara Cerniglia	TaMara Cerniglia Poor	TaMara Cerniglia Fair	TaMara Cerniglia Ok	TaMara Cerniglia Good	TaMara Cerniglia Great

Poor

Fair

Good

Great

Kim Brunson

Kim Brunson Poor

Kim Brunson Fair

Kim Brunson Ok

Kim Brunson Good

Kim Brunson Great

Lacey Brown

Lacey Brown Poor

Lacey Brown Fair

Lacey Brown Ok

Lacey Brown Good

Lacey Brown Great

Stacy Ferrell

Stacy Ferrell Poor

Stacy Ferrell Fair

Stacy Ferrell Ok

Stacy Ferrell Good

Stacy Ferrell Great

Joy Lockhartt

Joy Lockhartt Poor

Joy Lockhartt Fair

Joy Lockhartt Ok

Joy Lockhartt Good

Joy Lockhartt Great

Tiffany Freeman

Tiffany Freeman Poor

Tiffany Freeman Fair

Tiffany Freeman Ok

Tiffany Freeman Good

Tiffany Freeman Great

Lacey Russell

Lacey Russell Poor

Lacey Russell Fair

Lacey Russell Ok

Lacey Russell Good

Lacey Russell Great

Lori Cummings

Lori Cummings Poor

Lori Cummings Fair

Lori Cummings Ok

Lori Cummings Good

Lori Cummings Great

Madeline Gebhardt

Madeline Gebhardt Poor

Madeline Gebhardt Fair

Madeline Gebhardt Ok

Madeline Gebhardt Good

Madeline Gebhardt Great

TaMara Cerniglia

TaMara Cerniglia Poor

TaMara Cerniglia Fair

TaMara Cerniglia Ok

TaMara Cerniglia Good

TaMara Cerniglia Great

	Poor	Fair	Ok	Good	Great
Friendly and helpful to you.	Friendly and helpful to you. Poor	Friendly and helpful to you. Fair	Friendly and helpful to you. Ok	Friendly and helpful to you. Good	Friendly and helpful to you. Great
Answered your questions.	Answered your questions. Poor	Answered your questions. Fair	Answered your questions. Ok	Answered your questions. Good	Answered your questions. Great

Poor

Fair

Good

Great

Friendly and helpful to you.

Friendly and helpful to you. Poor

Friendly and helpful to you. Fair

Friendly and helpful to you. Ok

Friendly and helpful to you. Good

Friendly and helpful to you. Great

Answered your questions.

Answered your questions. Poor

Answered your questions. Fair

Answered your questions. Ok

Answered your questions. Good

Answered your questions. Great

	Poor	Fair	Ok	Good	Great
Overall cleanliness of our clinic.	Overall cleanliness of our clinic. Poor	Overall cleanliness of our clinic. Fair	Overall cleanliness of our clinic. Ok	Overall cleanliness of our clinic. Good	Overall cleanliness of our clinic. Great
Overall rating of care received during your visit.	Overall rating of care received during your visit. Poor	Overall rating of care received during your visit. Fair	Overall rating of care received during your visit. Ok	Overall rating of care received during your visit. Good	Overall rating of care received during your visit. Great
Likelihood of you recommending our practice to others.	Likelihood of you recommending our practice to others. Poor	Likelihood of you recommending our practice to others. Fair	Likelihood of you recommending our practice to others. Ok	Likelihood of you recommending our practice to others. Good	Likelihood of you recommending our practice to others. Great

Poor

Fair

Good

Great

Overall cleanliness of our clinic.

Overall cleanliness of our clinic. Poor

Overall cleanliness of our clinic. Fair

Overall cleanliness of our clinic. Ok

Overall cleanliness of our clinic. Good

Overall cleanliness of our clinic. Great

Overall rating of care received during your visit.

Overall rating of care received during your visit. Poor

Overall rating of care received during your visit. Fair

Overall rating of care received during your visit. Ok

Overall rating of care received during your visit. Good

Overall rating of care received during your visit. Great

Likelihood of you recommending our practice to others.

Likelihood of you recommending our practice to others. Poor

Likelihood of you recommending our practice to others. Fair

Likelihood of you recommending our practice to others. Ok

Likelihood of you recommending our practice to others. Good

Likelihood of you recommending our practice to others. Great

	Poor	Fair	Ok	Good	Great
How well did we respond to your medical questions in the same day?	How well did we respond to your medical questions in the same day? Poor	How well did we respond to your medical questions in the same day? Fair	How well did we respond to your medical questions in the same day? Ok	How well did we respond to your medical questions in the same day? Good	How well did we respond to your medical questions in the same day? Great
How well did we get you an appointment with your provider as soon as you needed it?	How well did we get you an appointment with your provider as soon as you needed it? Poor	How well did we get you an appointment with your provider as soon as you needed it? Fair	How well did we get you an appointment with your provider as soon as you needed it? Ok	How well did we get you an appointment with your provider as soon as you needed it? Good	How well did we get you an appointment with your provider as soon as you needed it? Great
How well have we responded to/taken care of your health needs?	How well have we responded to/taken care of your health needs? Poor	How well have we responded to/taken care of your health needs? Fair	How well have we responded to/taken care of your health needs? Ok	How well have we responded to/taken care of your health needs? Good	How well have we responded to/taken care of your health needs? Great

Poor

Fair

Good

Great

How well did we respond to your medical questions in the same day?

How well did we respond to your medical questions in the same day? Poor

How well did we respond to your medical questions in the same day? Fair

How well did we respond to your medical questions in the same day? Ok

How well did we respond to your medical questions in the same day? Good

How well did we respond to your medical questions in the same day? Great

How well did we get you an appointment with your provider as soon as you needed it?

How well did we get you an appointment with your provider as soon as you needed it? Poor

How well did we get you an appointment with your provider as soon as you needed it? Fair

How well did we get you an appointment with your provider as soon as you needed it? Ok

How well did we get you an appointment with your provider as soon as you needed it? Good

How well did we get you an appointment with your provider as soon as you needed it? Great

How well have we responded to/taken care of your health needs?

How well have we responded to/taken care of your health needs? Poor

How well have we responded to/taken care of your health needs? Fair

How well have we responded to/taken care of your health needs? Ok

How well have we responded to/taken care of your health needs? Good

How well have we responded to/taken care of your health needs? Great

Patient Satisfaction Survey

Question Title

* 1. Date of visit

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* 2. Patient's name (Optional):

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* 3. Patient's age:

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* 4. Patient's gender:

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* 5. Service site:

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* 6. Ease of getting care:

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* 7. Waiting:

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* 8. Front desk staff:

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* 9. Providers:

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* 10. Providers:

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* 11. Nurses and Medical Assistants:

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* 12. Overall Assessment:

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* 13. In the last 12 months:

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* 14. Please share any suggestions or comments you have about Mercy Medical Health Center: