Patient Satisfaction Survey

Name of the doctor this survey is about:*
We are interested in receiving your feedback about the care provided at our office. Please take a few minutes to complete this survey and return it to us. Your responses are important to us.

How satisfied are you with the following?*

	Extremely Dissatisfied	Very Dissatisfied	Satisfied	Very Satisfied	Extremely Satisfied
Ease of making appointment for checkups (physical exams, well visits, routine follow-up appointments)?
Ease of making appointments for sickness?
Ease in contacting your doctor when our office is closed (nights and weekends)?
Ease in speaking directly with your doctor by telephone when you call during office hours?
The time it takes someone from our office to respond when you call the office with an urgent problem?
Waiting time in our office?
Ease in obtaining follow-up information and care (test results, medicines, care instructions)?
Overall medical care at your doctor’s office?
Our office’s appearance?
Our office’s convenience (location, parking, hours, of ce layout)?
The way we teach you about improving your health?
The way your doctor involves other doctors and caregivers in your care when needed?

How caring would you say the following individuals are?*
Extremely Uncaring Very Uncaring Caring Very Caring Extremely Caring
Your doctor?
Our medical staff?
Our office staff?
Would your recommend your doctor to your family or friends?*
Definitely Not Probably Not Not Sure Probably Definitely
These questions pertain to the patient to whom this survey was addressed:
Age in years*
- <1
- 1-4
- 5-9
- 10-19
- 20-29
- 30-39
- 40-49
- 50-59
- 60-65
- 66-75
- 75+
Gender*
- Male
- Female
How long have you been a patient of this doctor?*
- Less than 1 year
- 1-4 years
- 5-9 years
- 10 years or more
How many times have you visited Lakewood Family Clinic in the past 12 months for medical care?*
- 0
- 1
- 2
- 3
- 4
- 5
- 6 or more
These questions pertain to the responsible party:
The name of your health plan:
The name of your employer:
Your level of education:
- 8th grade or less
- Some high school
- High school graduate
- Some college
- College graduate
- Post-graduate degree
Comments:

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We are interested in receiving your feedback about the care provided at our office. Please take a few minutes to complete this survey and return it to us. Your responses are important to us.