Physical Therapy Extension Form | Synovation Medical Group


SYNOVATION MEDICAL GROUP Patient Survey
Please take a moment to evaluate your experience at us so we may learn how to better serve you.
Provider seen today: or: Other provider:
Visit Date: (example 01/23/11)
1. Overall, how satisfied are you with the Doctor you saw today? Extremely Satisfied Satisfied Somewhat Satisfied Neither Satisfied nor Dissatisfied Somewhat Dissatisfied Very Dissatisfied Completely Dissatisfied
2.	Your ease of contacting the group by phone was	Excellent Very Good Good Fair Poor
3.	Your ability to speak with the doctor or nurse on the phone was	Excellent Very Good Good Fair Poor
4.	The amount of days you waited for your appointment was	Excellent Very Good Good Fair Poor
5.	The cleanliness and comfort of the office was	Excellent Very Good Good Fair Poor
6.	The office wait time to see the doctor was	Excellent Very Good Good Fair Poor
7.	The courtesy and helpfulness of the office receptionist was	Excellent Very Good Good Fair Poor
8.	The courtesy and helpfulness shown to you by the medical assistants	Excellent Very Good Good Fair Poor
9.	Your ability to speak with the doctor or nurse on the phone was	Excellent Very Good Good Fair Poor
Thinking about the care provided by the Doctor, how would you rate:
10.	How well did the doctor explain what he/she was doing and why?	Excellent Very Good Good Fair Poor
11.	How well did the doctor use words that were easy to understand?	Excellent Very Good Good Fair Poor
12.	How well did the doctor listen to your concerns or questions?	Excellent Very Good Good Fair Poor
13.	How well did the doctor answer your questions?	Excellent Very Good Good Fair Poor
14.	How was the warmth and caring demonstrated to you by the doctor?	Excellent Very Good Good Fair Poor
15.	How was the amount of time you had with the doctor during your visit?	Excellent Very Good Good Fair Poor
16. What impressed you most about the doctor?
17. What could be improved?
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