Classic list

1. Please rate your experience level regarding the topics listed below:

Experience:
1=Not Satisfied at All       5=Very Satisfied

Your overall experience with your visit
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Length of time you waited to make an appointment
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Courtesy of the person at the front desk
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Friendliness of the person at the front desk
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Length of time you waited in the reception area
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Courtesy of the person who took you to the exam room
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Length of time the healthcare provider spent with you
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Check One: PhysicianPhysician Assistant

Explanation of the treatment plan
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Length of time available to answer all of your questions
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Explanation of the purpose of the prescribed medications, dosages, and any side effects
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2. Please rate your level of understanding of the topics below:

1= Do not Understand at All     5=Understand Completely

Your main medical problem
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What you need to do about your problem
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Why you need to follow instructions
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How to contact our office
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3. Please tell us how we could improve our service:

4. Please enter your name.

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