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  2. 2015
  3. November
  4. P
  5. Patient satisfaction survey #3
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Exit Survey
 
 
Hello:
We need you help ! In order to give our patients the best healthcare we can we need to know what we need to improve upon and what we're doing right. Please take a few minutes to answer a few questions
 
 
 
Age ?
 
0-12 13-18 19-30 31-50 51-64 65 +
 
 
 
Gender ?
 
Male Female Other
 
 
Which provider do you see ?
 
Dr Depner Linda Pullman Brad Speta
 
 
Highest level of education completed ?
 
8th grade or less Some high school 12th grade GED
 
Some College College or Vocational Degree
 
Four year College More than four year College
 
How satisfied are you with the following:
Very Dissatisfied Not Satisfied Neutral Satisfied Very Satisfied
Ease of Scheduling routine appointments ?
Ability of being seen within 24 hours for illness/injury ?
Being treated with courtesy and respect ?
The knowledge of your provider about your health care ?
 
 
Did you have any other services ordered today ?
 
Labs
 
Radiology (x-rays ,ultrasounds,CT's MRI's,Mammograms,Dexa)
 
Referrals to a Specialist
 
How would you rate your health ?
Great Good Average Fair Poor
Overall Health
Physical health
Mental health
 
 
Which of the following hinders improvement to your health ?
 
Age
 
Lack of mobility
 
Lack of insurance/Inadequate insurance
 
Financial restraints
 
Lack of personal support/caregivers
 
Depression
 
Unknown
 
None of the above/No hindrances