Patient Satisfaction Template Question Title * 1. How likely is it that you would recommend your provider to a friend or family member? Not at all likely Extremely likely 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 Question Title * 2. Overall, how satisfied or dissatisfied were you with your last visit to our office? Very satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Very dissatisfied Question Title * 3. How easy or difficult was it to schedule your appointment at a time that was convenient for you? Very easy Somewhat easy Neither easy nor difficult Somewhat difficult Very difficult Question Title * 4. How convenient was the appointment time you were able to get? Extremely convenient Very convenient Somewhat convenient Not so convenient Not at all convenient Question Title * 5. Have you visited the practice website? yes no Question Title * 6. If you have visited the practice website, what did you think? There is a good amount of information It needs more information Useful Not useful Question Title * 7. In your opinion, how convenient is the location of our office? Extremely convenient Very convenient Somewhat convenient Not so convenient Not at all convenient Question Title * 8. Overall, how would you rate the service you received from the staff at our office? Excellent Very good Good Fair Poor Question Title * 9. How comfortable was the lobby and waiting area? Extremely comfortable Very comfortable Somewhat comfortable Not so comfortable Not at all comfortable Question Title * 10. Did your appointment with your provider start early, late or on time? Very early Somewhat early On time Somewhat late Very late Question Title * 11. Overall, how would you rate the care you received from your provider? Excellent Very good Good Fair Poor Question Title * 12. How much do you trust your provider to make medical decisions that are in your best interests? A great deal A lot A moderate amount A little Not at all Question Title * 13. How well did your provider listen to your needs? Extremely well Very well Somewhat well Not so well Not at all well Question Title * 14. How well did your provider answer your questions? Extremely well Very well Somewhat well Not so well Not at all well Question Title * 15. How well did your provider explain your treatment options? Extremely well Very well Somewhat well Not so well Not at all well Question Title * 16. How well did your provider explain your follow-up care? Extremely well Very well Somewhat well Not so well Not at all well Question Title * 17. How satisfied or dissatisfied were you with the amount of time your provider spent with you addressing your needs? Very satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Very dissatisfied Question Title * 18. Is there anything we could have done to improve your last visit? Question Title * 19. Are you willing to be contacted regarding your feedback? Question Title * 20. Please provide your preferred contact details Next
