Address:
717 South 8th Street
Griffin, GA 30224

It is our goal to give you the best possible medical care. To do that, it is important that we know your thoughts about the care you are receiving. We need to know what we are doing right and in what areas we need to improve. Your comments will be kept strictly confidential. You may make additional comments on the other side of this survey. Thank you for your help.

Name of your doctor: *
 
1. Is this your New patient first visit
Scheduled follow-up of ongoing medical problems
Evaluation of an acute illness
 
2. Why did you decide to seek
medical treatment at this office?
(Please select one) 		Near my office or home
Referred by another patient
Referred by another physician
Referred by local medical society
Telephone listing
Other:
 
3. Did you have any difficulty getting
an appointment in a timely manner?		 Yes
No
If yes, please explain:
 
4. When you called, The telephone was answered promptly
I was put on hold ( Minutes )
The line was busy

How many times was it busy when you called? 

 

5. The person who answered
your call was:
(Courteous=5; Discourteous=1)

 5 4 3 2 1
 

6. How were you treated when
you arrived for your appointment?
(Pleasantly=5; Unpleasantly=1)

 5 4 3 2 1
 

7.How long did you have to wait
to see your physician after
your scheduled appointment time?

minutes
 
8. The nurse seemed:
(Friendly and interested=5; Impersonal=1) 		5 4 3 2 1
 

9. How were you treated
by the office staff during your visit?
(Pleasantly=5; Coldly=1)

 5 4 3 2 1
 
10.  Were you satisfied with
the amount of time
the doctor spent with you?
(Very Satisfied=5; Very Dissatisfied=1) 		5 4 3 2 1
 
11. The doctor was:
(Interested in your problem=5; Indifferent=1) 		5 4 3 2 1
 

12. The doctor's explanation
of your illness and treatment was:
(Excellent=5; Inadequate=1)

 5 4 3 2 1
 
13. Were you satisfied with
the medical treatment you received?
(Very Satisfied=5; Very Dissatisfied=1) 		5 4 3 2 1
 
14. Did your doctor explain
your medication to you? 		Yes
No
 
15. Do you believe that the fees
are appropriate for services rendered? 		Yes
No
 

16. What is your experience
with the business office and the
billing procedure?
(Excellent=5; Inadequate=1)

 5 4 3 2 1
 
17. Do you wish to be personally contacted about any concerns or questions you have?

Yes
No
 
Name (optional):
Phone (optional):

Additional Comments:
 



Thanks again for filling out
this questionnaire.