How Are We Doing?

General Patient Information

In general what is the quality of your health?
OutstandingGoodSome chronic IssuesPoor

How would you rate our concern for your privacy?
OutstandingGoodAdequateNeeds ImprovementPoor

How often have you visited Hardee Family Medicine within the past year?
First Visit2-5 VisitsMore than 6

Schedule Your Appointment

Did you schedule an appointment by phone or did you routine follow-up?
Scheduled by phoneRoutine follow-up

If you scheduled an appointment, did you have to wait longer than expected to get scheduled?
YesNo

How easy was it to make an appointment by telephone?
Very EasyEasyDifficultVery Difficult

How long did you wait to speak to a scheduling staff member?
0 to 2 minutes3 to 5 minutes5 to 7 minutesLonger

Was the person who scheduled your appointment courteous and helpful?
Very courteousRude

If you were seeking a referral to a specialist, was your request handled in a timely manner?
YesNo

Day Of Your Appointment

Date:

How would you rate the courtesy of the staff at the reception desk?
Very courteousRude

How long did you wait in the reception area beyond your scheduled appointment time?
0 to 5 minutes5 to 20 minutes20 to 40 minutesMore than 40 minutes

How long did you wait in the exam room before the physician appeared?

0 to 5 minutes5 to 20 minutes20 to 40 minutesMore than 40 minutes

Which department(s) did you visit during your appointment?
Physician VisitPhysician Assistant VisitNurse VisitLabBilling

The Nursing Staff

How would you rate the competence of the nurse who helped you?

OutstandingGoodAdequateNeeds ImprovementPoorN/A

How would you characterize the concern that the nurse showed for your problem?
OutstandingGoodAdequateNeeds ImprovementPoorN/A

Did the nurse respond to your requests within a reasonable period?
YesNo

Physician or Physician Assistant

Name:

Were you able to see the provider of your choice?
YesNoN/A

Did you feel that your provider spent an adequate amount of time with you?
YesNoN/A

Mark the boxes that characterize the demeanor of your provider:
AttentiveConcernedFriendlyDistractedRushedInconsiderateBilling

How would you rate the competence of your provider?
OutstandingGoodAdequateNeeds ImprovementPoorN/A

Did you feel that your provider's examination was thorough?
YesNoN/A

Please rate the clarity of the provider's explanation of your condition and treatment options:
OutstandingGoodAdequateNeeds ImprovementPoorN/A

How well did your provider include you in healthcare decisions?
OutstandingGoodAdequateNeeds ImprovementPoorN/A

Were your questions answered to your satisfaction?
YesNoN/A

Would you recommend this facility and its staff to your family and friends?
YesNoN/A

The Lab Staff

How would you rate the professionalism and competence of the person who took your blood and worked on your lab exam?
OutstandingGoodAdequateNeeds ImprovementPoorN/A

If you received a lab exam, please indicate the type(s) of lab exam you received:
Blood testBreast examPap ExamUrinalysisOther

If other exam, what was it?

If you received a lab exam, was the service prompt, comfortable, and courteous?
YesNoN/A

Additional Feedback

Please list any areas in which our service could be improved.

Please share any additional comments.

Personal Information

Providing the following information is optional.

First Name

Last Name

Street Address

City

State

Zip

Sex
MaleFemalePrefer not to say

Age

Would you like someone to contact you regarding your responses on this survey?
YesNo