*This form should be printed and brought or mailed to the office. Our Mailing address can be obtained from our Office Information page.

PATIENT'S NAME ______________________________________

PHYSICIAN SEEN ______________________________________

DATE OF VISIT ________________________________________

Please consider your visit to the doctor and answer the following questions by circling the number in each line.

	Poor	Fair	Good	Very Good	Excellent
1. How long you waited to get an appointment	1	2	3	4	5
2. Convenience of the location of the office	1	2	3	4	5
3. Getting through to our office by phone	1	2	3	4	5
4. Length of time waiting at the office	1	2	3	4	5
5. Time spent with the person you saw	1	2	3	4	5
6. Explanation of what was done for you	1	2	3	4	5
7. The technical skills (thoroughness, carefulness, competence) of the person you saw	1	2	3	4	5
8. The personal manner (courtesy, respect, sensitivity, friendliness) of the person you saw	1	2	3	4	5
9. The visit overall	1	2	3	4	5
10. In general, would you say your health is	1	2	3	4	5
11. Are you (patient) male or female?	Male		Female
12. How old were you (patient) on your last birthday?	(Write in) ____________ years
Comments:

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