| Address 1 | Address 2 | City, State ZIP | Telephone | Fax

Patient Satisfaction Survey !utpatient !ffice1

We want to be sure we are doing everything we can to serve you. Please take a minute to fill out this confidential survey. Just let us know what we are doing well and what we can to do better! Thank you. "our physician#provider I saw 1$ Please indicate your level of satisfaction %ith the follo%in& ite's related to your office appoint'ent$ (se a scale of 1 to ), %ith ) *ein& +ery Satisfied and 1 *ein& ,ot at all Satisfied$ If an ite' is not related to your care, choose ,#A$ ,ot at all Satisfied -1. Getting through to the office by phone. The time between your call to schedule an appointment and your appointment date. The manners of the person!s" who scheduled your appointment. #larity of directions to the office and the time of your appointment. The professionalism and helpfulness of your reception. $our wait time in the office. The comfort% cleanliness and amenities of the reception area. The e&tent to which staff respected your privacy. 2$ Please rate the follo%in& ite's related to the delivery of your care$ (se a scale of 1 to ), %ith ) *ein& 1xcellent and 1 *ein& Poor$ If an ite' is not related to your care, choose ,#A$ Poor -1. $ou physician'provider(s listening skills. )is or her e&planation of procedures% diagnoses or treatment regimen. )is'her personal manner !courtesy% respect% sensitivity% friendliness" . ther staff(s personal manner !courtesy% respect% sensitivity% friendliness" . Technical skills !thoroughness% carefulness% competence" of the physician'practitioner. )ow prepared !records and educational materials readily available" the staff and physician'provider were for your visit. -2. -/. -0. 1xcellent ,#A -). ,eutral -/. +ery Satisfied ,#A -).

-2.

-0.

*dapted from #linic and +ndoscopy Patient #are +&perience ,uestions -../% 0innesota Gastroenterology% P.*. #opyright 1 -..2 by the *G* Institute

1xa'ple Practice | Address 1 | Address 2 | City, State ZIP | Telephone | Fax /$ Please indicate the extent to %hich you a&ree or disa&ree %ith each of the follo%in& state'ents$ (se a scale of 1 to ), %ith ) *ein& Stron&ly A&ree and 1 *ein& Stron&ly 2isa&ree$ If an ite' is not related to your care, choose ,#A$ Stron&ly So'e%hat So'e%hat Stron&ly 2isa&ree 2isa&ree ,eutral A&ree A&ree ,#A -1. -2. -/. -0. -).

0y physician'provider spent ade3uate time with me. The service'care provided was valuable to improving my health. The educational information I received was helpful. I clearly understand the ne&t steps in my plan of care. 0$ If la* %or3 %as done, did you receive your la* results in a ti'ely 'anner follo%in& your office visit4 ! "es ! ,o ! ,ot applica*le

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5ould you return to see this physician#practitioner for further care4 ! "es ! ,o

6$

5ould you reco''end this practice to fa'ily and friends4 ! "es ! ,o

7$

a$ *$

2id any specific staff 'e'*er stand out4 If yes, %ho and %hy4

! "es

! ,o

8$

a$ *$

5as there any aspect of your care that could *e i'proved4 If yes, please explain$

! "es

! ,o

1xa'ple Practice | Address 1 | Address 2 | City, State ZIP | Telephone | Fax

#opyright 1 -..2 by the *G* Institute

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Please tell us %hat you li3e *est a*out the care you received$

1:$

Please tell us %hat you li3e least a*out the care you received$

#opyright 1 -..2 by the *G* Institute