Patient Satisfaction Survey

Survey Instructions

Answer each question by marking the box to the left of your answer. You may be asked to skip some questions in this survey. When this happens, you will see a note that tells you what question to answer next.

Name*

First Last

Email*

Date of birth*

Please select your provider.*

The questions in this survey will refer to the provider named above as “this provider.” Please think of that person as you answer the survey.

Your Provider

1.*

Our records show that you've received care from this provider named above in the last 6 months.

Yes
No (If No, skip to question #23 )

2.*

Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

Yes
No

3.*

How long have you been going to this provider?

Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more

Your Care From This Provider in the Last 6 Months

These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.

4.*

In the last 6 months, how many times did you visit this provider to get care for yourself?

None (If None, skip to question #23)
1 Time
2 Times
3 Times
4 Times
5 to 9 Times
10 or more times

5.*

In the last 6 months, did you contact this provider’s office to get an appointment for an illness, injury, or condition that needed care right away?

Yes
No (If No then skip to question #7)

6.*

In the last 6 months, when you contacted this provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

Never
Sometimes
Usually
Always

7.*

In the last 6 months, did you make any appointments for a check-up or routine care with this provider?

Yes
No (If No then skip to question #9)

8.*

In the last 6 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?

Never
Sometimes
Usually
Always

9.*

In the last 6 months, did you make any appointments for a check-up or routine care with this provider?

Yes
No (If No then skip to question #11)

10.*

In the last 6 months, when you contacted this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

Never
Sometimes
Usually
Always

11.*

In the last 6 months, how often did this provider explain things in a way that was easy to understand?

Never
Sometimes
Usually
Always

12.*

In the last 6 months, how often did this provider listen carefully to you?

Never
Sometimes
Usually
Always

13.*

In the last 6 months, how often did this provider seem to know the important information about your medical history?

Never
Sometimes
Usually
Always

14.*

In the last 6 months, how often did this provider show respect for what you had to say?

Never
Sometimes
Usually
Always

15.*

In the last 6 months, how often did this provider spend enough time with you?

Never
Sometimes
Usually
Always

16.*

In the last 6 months, did this provider order a blood test, x-ray, or other test for you?

Yes
No (If no skip to question #18)

17.*

In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?

Never
Sometimes
Usually
Always

18.*

Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

19.*

In the last 6 months, did you take any prescription medicine?

Yes
No (If no skip to question #21)

20.*

In the last 6 months, how often did you and someone from this provider’s office talk about all the prescription medicines you were taking?

Never
Sometimes
Usually
Always

Clerks and Receptionists at This Provider’s Office

21.*

In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be?

Never
Sometimes
Usually
Always

22.*

In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect?

Never
Sometimes
Usually
Always

About You

23.*

In general, how would you rate your overall health?

Excellent
Very Good
Good
Fair
Poor

24.*

In general, how would you rate your overall mental or emotional health?

Excellent
Very Good
Good
Fair
Poor

25.*

What is your age?

26.*

Are you male or female?

Male
Female
Third Choice

27.*

What is the highest grade or level of school that you have completed?

8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

28.*

Are you of Hispanic or Latino origin or descent?

Yes, Hispanic or Latino
No, not Hispanic or Latino

29.*

What is your race? Mark one or more.

White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other

30.*

Did someone help you complete this survey?

Yes
No

31.*

If Yes. How did that person help you? Mark one or more.

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
I was not helped

Patient Satisfaction Survey