Review Survey Template  

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 wi
1. Your Age
18 to 25
26 to 35
36 to 45
46 to 55
56 to 65
Over 65
2. Your sex
Male
Female
3. Your race or ethenicity
Asian
Pacific Islander
Spanish
White
Black
Unknow
4. Easy of Gettig Care: Please circle how well you do in the following based on the following rating scale: 1 = Poor, 2 = Fair, 3 = OK, 4 = Good, 5 = Great
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Ability to get in to be seen
Hours Center is open
Convenience of Center’s location
Prompt return on calls
5. Waiting:

Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good, 5 = Great
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Time in waiting room
Time in exam room
Waiting for tests to be performed
Waiting for test results
6. Nurses and Medical Assistants:
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good
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Friendly and helpful to you
Answers your questions
Gives you good advice and treatment
Explains what you want to know
7. Payment:
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good
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What you pay
Explanation of charges
Collection of payment/money
8. Facility:
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good
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Neat and clean building
Ease of finding where to go
Comfort and Safety while waiting
Privacy
9. Confidentiality:
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good
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Keeping my personal information private
10. The likelihood of referring your friends and relatives to us:
Very highly
Highly
Maybe
Not Sure
Never
11. Do you consider this center your regular source of care?
Yes
No
12. What do you like best about our center?
13. What do you like least about our Center?
14. Suggestions for improvement?