Was the person who scheduled your appointment courteous and helpful?

Select No Yes N/A

In general, what is the quality of your health?

Select Outstanding Good Adequate Needs improvement Poor

How would you rate our concern for your privacy?

Select Outstanding Good Adequate Needs improvement Poor N/A

How often have you visited Gulf Coast Medical Care within the past year?

Select First Visit 2-5 Visits More than 6

Did you schedule an appointment by phone or did you drop in?

Select By phone Dropped in

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

Select No Yes

How easy was it to make an appointment by telephone?

Select Very easy Somewhat easy Not easy Difficult Very difficult

How long did you wait to speak to a scheduling staff member?

Select 0 to 2 minutes 3 to 5 minutes 5 to 7 minutes 7 + minutes

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

Select No Yes

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

Select Outstanding Good Adequate Needs improvement Poor N/A

How long did you wait in the reception area beyond your scheduled appointment time?

Select 0 to 5 minutes 5 to 20 minutes 20 to 40 minutes 40 + minutes

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

Select 0 to 5 minutes 5 to 20 minutes 20 to 40 minutes 40 + minutes

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

Select Outstanding Good Adequate Needs improvement Poor N/A

How would characterize the concern that the nurse showed for your problem?

Select Outstanding Good Adequate Needs improvement Poor N/A

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

Select No Yes

Were you able to see the doctor of your choice?

Select No Yes N/A

Did you feel that your doctor spent an adequate amount of time with you?

Select No Yes N/A

Mark the boxes that characterize the demeanor of your doctor.

Select Attentive Concerned Friendly Distracted Rushed Inconsiderate

How would you rate the competence of your doctor?

Select Outstanding Good Adequate Needs improvement Poor N/A

Did you feel that your doctor’s examination was thorough?

Select No Yes N/A

Please rate the clarity of the doctor’s explanation of your condition and treatment options.

Select Outstanding Good Adequate Needs improvement Poor N/A

How well did your doctor include you in healthcare decisions?

Select Outstanding Good Adequate Needs improvement Poor N/A

Were your questions answered to your satisfaction?

Select No Yes N/A

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

Select No Yes N/A

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

Select Outstanding Good Adequate Needs improvement Poor N/A  

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

Select Yes No N/A

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