Patient Survey

Name:
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Email Address:
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Home address:
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Home Phone #:
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Work Phone #:
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Insurance:

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Who was your Physician?

What location did you visit?

Did you find our office location convenient?

Yes No

How did you hear about us?

Please use the following scale to answer the questions below:
5 = Excellent | 4 = Very good | 3 = Average | 2 = Poor | 1 = Very poor

1. How would you rate our switchboard and telephone service?
   :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor
2. Did you find it easy to make an appointment?
   :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor
3. Was our staff helpful?
   :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor
4. Did the doctor clearly explain the problem and the treatment he prescribed?
   :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor
5. Did you feel that the doctor was truly concerned for your well-being?
   :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor >
6. Did your physician spend adequate time with you during your visit?
   :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor
7. Did you feel that your check out and bill payment was courteous and efficient?
   :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor
8. Was the staff helpful in helping you with your insurance coverage?
   :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor
9. Did our medical assistants make you feel comfortable?
   :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor
10. Do you feel you received the highest quality of care from your physician?
    :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor
11. Please rate your overall experience and quality of care provided by PBOI?
    :: select one :: 5 Excellent 4 Very good 3 Average 2 Poor 1 Very poor
12. What was your wait time?
    :: select one :: 10 minutes 20 minutes 30 minutes 40 minutes 50 minutes 1 hour
13. How many miles did you travel to reach our office?
    Please use only numbers

Would you recommend PBOI to your family and friends?
YesNo

If you answered no, please explain:

Do you have any comments or recommendations on how we might serve you better?

 
Please use only letters, numbers, and punctuation

Would you like to be added to our Mailing List?

YesNo