Patient Satisfaction Survey form

Download and use this form for your Patients to give them a Satisfaction Survey.

Patient Satisfaction Survey form

Text Version of this Form

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Patient Questionnaire

Gender: Male Female Marking Instructions
Please indicate your answer by filling in the bubble
25 or under 45-54
like this, not like x or !
26-34 55-64

35-44 65 and over

Over the last five years how often have you seen this
doctor? Once 2-3 times Over 3 times

Today’s visit is mainly for: Interpretation of the Rating Scale
Answer the questions about this doctor using the
New concern Ongoing concern Examination

Physician’s Name: Strongly Disagree Neutral Agree Strongly Not

Disagree Agree Applicable
1 2 3 4 5 NA

Based on the MOST RECENT VISIT to your doctor:

1. Your doctor explained your illness or injury to you thoroughly

2. Your doctor adequately explained your treatment choices

3. Your doctor clearly explained your problem and how to avoid it
in the future

4. Your doctor explained when to return for follow-up care

If your doctor gave you a prescription for medicine:

5. Your doctor clearly explained how and when to take your medicine

6. Your doctor told you of any side effects of the medicine

Based on the ALL OF YOUR VISITS to your doctor’s office,
how do you feel about your doctor’s attitude and behavior
towards you? My doctor:

7. Spends enough time with me

8. Shows interest in my problems

9. Asks details about my personal life, when appropriate

10. Answers my questions well

11. Examines me appropriately for my problems

12. Treats me with respect

13. Helps me with my fears and worries

14. Talks with me about treatment plans

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Strongly Disagree Neutral Agree Strongly Not
Disagree Agree Applicable
1 2 3 4 5 NA

Rate each statement about your doctor’s office. The office:

15. Is easy to get into (e.g. parking, wheelchair, etc.)

16. Has sufficient waiting areas

17. Examining rooms are adequately sized and have adequate

18. Is clean and in good repair

19. Provides adequate privacy

How do you feel that your doctor runs his or her practice?

20. It is easy to reach the office by phone during the day

21. I am able to reach a doctor by telephone after office hours

22. In urgent cases, a doctor is available by phone

The Staff:
23. Is very capable

24. Is helpful and pleasant

25. Is respectful of patients

26. Behaves in a professional manner

27. Works well with my doctor

28. Prevents patients from hearing confidential information about
other patients

Office Practices:
29. I can get an appointment quickly

30. I do NOT wait long in the reception area for my appointment

31. When asked, my doctor provides reports, files, or copies of letters

32. I am advised of results of tests or x-rays

33. My doctor arranges appointments with specialists when necessary

34. Someone from my doctor’s office follows-up on any serious
problems I may have

35. I am told what to do if my problems do not get better


36. My physician talks to me about preventative care (e.g. quitting
smoking, weight control, sleeping, alcohol, exercise, etc.)

37. My doctor asks regularly about prescription and
non-prescription medicine I may be taking

38. My doctor has printed health information available

39. I would go back to this doctor

40. I would send a friend to this doctor

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