Patient Satisfaction Survey – Primary Care

To our valued patients:
Your comments are very important to us and will help us improve services.
Yes /

No

Is this your first visit to this Health Center? / O / O

How are we doing in the following areas?

1. /

Appointments

/

Poor

/ Fair / Good / Great /

Don’t Know

Ease of scheduling by phone / O / O / O / O / O
Ability to get one soon enough for your needs / O / O / O / O / O
2. /

Appointment/Registration

/

Poor

/ Fair / Good / Great / Don’t Know
Courtesy and friendliness of appointment/ registration staff / O / O / O / O / O
3. /

Facility

/

Poor

/ Fair / Good / Great / Don’t Know

Convenience of Health Center hours

/ O / O / O / O / O

Cleanliness of the Health Center

/ O / O / O / O / O
4. /

Respect and Safety

/

Poor

/ Fair / Good / Great / Don’t Know

Our concern for your safety and security

/ O / O / O / O / O

Our effort to keep your personal information confidential

/ O / O / O / O / O

Our respect for your privacy in the exam room

/ O / O / O / O / O
Yes /

No

Has the Center provided information to you and your family on how to prevent infections (hand washing, covering mouth & nose when coughing)? / O / O
When your medications have been changed by your provider, have you been given a list of all your medications by your provider or nurse? / O / O
5. /

Waiting Time

/ Poor / Fair / Good / Great /

Don’t Know

Amount of time you wait to see your provider

/ O / O / O / O / O
6. /

Nurses and Medical Assistants

/

Poor

/ Fair / Good / Great / Don’t Know

Courtesy and friendliness of nursing staff

/ O / O / O / O / O

Concern shown for your health problem

/ O / O / O / O / O
Administrative use only:
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7a. /

Your Doctor and Other Health Providers

/ Poor / Fair / Good / Great /

Don’t Know

How well does your doctor listen to you and answer your questions?

/ O / O / O / O / O

Amount of information you get about your health

/ O / O / O / O / O

Your confidence in this doctor/provider

/ O / O / O / O / O

When you have told your provider that you have pain, how well was your pain managed?

/ O / O / O / O / O

How has the Center’s response time been to your telephone messages?

/ O / O / O / O / O
7b. /

Interpreter

/ Yes /

No

Do you and your doctor speak the same language? / O / O
/ Poor / Fair / Good / Great /

Don’t Know

If not, how well do you understand your provider through the Health Center interpreter?

/ O / O / O / O / O
8. /

Overall

/

The likelihood that you would recommend this Center to others?

/ O / O / O / O / O

Please tell us how we could improve services:

Please tell us about yourself.
These questions are voluntary and help us give all patients the best services.
Female /

Male

What is your age? / / What is your sex? / O / O
What is your background? / O Chinese / O Puerto Rico / O African-American
O Other Asian / O Dominican / O Caribbean-American
O Arabic / O Mexican / O White
O American Indian / O Other latino/Hispanic / O Other

Thank you for completing our survey

Administrative use only:
O SP-MED O SP-WH O SP-PED O SP-SPC O SP-MFM O BC O CA O PF O PR O PS O SR O SCIS