Coastal Cardiology, P.C. Patient Forms
MEDICAL PRACTICE SURVEY
We thank you in advance for completing this questionnaire. When you are finished, please click the SEND SURVEY button at the bottom.
BACKGROUND QUESTIONS [write in answer or select appropriate box]
1. If someone other than the patient is completing this survey, please check this box:
2. Date of Visit: mm/dd/yyyy
3. Patient's first visit here..... Yes   No
4. Patient's Sex .......... Male   Female
5. Patient's Age in years...
 
6. How many minutes did you wait after your scheduled appointment time before you were called to an exam room?
minutes
7. How many minutes did you wait in the exam room before you were seen by a doctor, phyisican assistant (PA) or Nurse Practitioner (NP)?
minutes

INSTRUCTIONS: Please rate the services you received from our practice.  Check the appropriate circle that best describes your experience. If a question does not apply to you, please skip to the next question.  Space is provided for you to comment on good or bad things that may have happened to you. The following questions pertain to visits to your physician's office only; this survey does not include visits to hospitals or other locations.
A. ACCESS TO CARE very poor poor fair good very good
1. Ease of scheduling your appointment 1 2 3 4 5
2. Ability of getting an appointment for when you wanted 1 2 3 4 5
3. Courtesy of person who scheduled you appointment 1 2 3 4 5
4. Our helpfulness on the telephone 1 2 3 4 5
5. Our promptness in returning your phone calls 1 2 3 4 5
Comments (describe good or bad experience)
 
B. DURING YOUR VISIT very poor poor fair good very good
1. Speed of the registration process 1 2 3 4 5
2. Courtesy of staff in the registration area 1 2 3 4 5
3. Comfort and pleasantness of the waiting area 1 2 3 4 5
4. Length of wait before going to an exam room 1 2 3 4 5
5. Comfort and pleasantness of the exam room 1 2 3 4 5
6. Friendliness/courtesy of the nurse/assistant/technician 1 2 3 4 5
7. Concern the nurse/assistant show 1 2 3 4 5
8. Waiting time in the exam room before being seen by the care provider 1 2 3 4 5
Comments (describe good or bad experience)
 
C. YOUR CARE PROVIDER very poor poor fair good very good
DURING YOUR VISIT, YOUR CARE WAS PROVIDED PRIMARILY BY A PHYSICIAN
PLEASE ANSWER THE FOLLOWING QUESTIONS WITH THAT HEALTH CARE PROVIDER IN MIND.
1. Friendliness/courtesy of the care provider 1 2 3 4 5
2. Explanations the care provider gave you about your problem or condition 1 2 3 4 5
3. Ease of obtaining test results 1 2 3 4 5
4. Concern the care provider showed for your questions or worries 1 2 3 4 5
5. Care provider's efforts to include you in decisions about your treatment 1 2 3 4 5
6. Information the care provider gave you about medications (if any) 1 2 3 4 5
7. Instructions the care provider gave you about follow-up care (if any) 1 2 3 4 5
8. Degree to which care provider talked with you using words you could understand 1 2 3 4 5
9. Amount of time the care provider spent with you 1 2 3 4 5
10. Your confidence in this care provider 1 2 3 4 5
11. Likeliehood of your recommending this care provider to others 1 2 3 4 5
Comments (describe good or bad experience)
 
D. PERSONAL ISSUES very poor poor fair good very good
1. Convenience of our office hours 1 2 3 4 5
2. Our sensitivity to your needs 1 2 3 4 5
3. Our concern for your privacy 1 2 3 4 5
Comments (describe good or bad experience)
 
E. BILLING very poor poor fair good very good
1. Clarity of billing statements 1 2 3 4 5
2. Accuracy of billing statements 1 2 3 4 5
3. Promptness with which questions or problems about your bill were resolved 1 2 3 4 5
4. Our assistance with your insurance or billing questions 1 2 3 4 5
Comments (describe good or bad experience)
 
F. OVERALL ASSESSMENT very poor poor fair good very good
1. Overall cheerfulness of our practice 1 2 3 4 5
2. Overall Cleanliness of our practice 1 2 3 4 5
3. Overall rating of care received during your visit 1 2 3 4 5
4. Likeliehood of your recommending our practice to others 1 2 3 4 5
Comments (describe good or bad experience)
 
OPTIONAL
Telephone Number: