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We invite you to take a sample survey as if you were a patient – just go to our home page and enter the code 1234 1234 1234 1234 on the patient’s section. You will then be given access to respond to a survey for a fictional doctor. Go ahead and answer whatever you want until you reach the end of the survey.
Please see below the survey questionnaire.
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Thank you for agreeing to provide feedback to Dr. [Name of Doctor]. Your doctor wants your help to continually improve the services offered to patients. We appreciate your candid response to the 5-minute online anonymous questionnaire below. By answering the questionnaire, you may choose to enter for a chance to win a gift card.
- Is this the first time you visited this doctor?
- Why did you choose to visit this specific doctor?
On a scale of 1 (=worst) to 10 (=best), please rate your experience with the healthcare professional:
About the professional:
- How would you rate your overall experience with the visit to this healthcare professional? (1 = Very poor; 10 = Excellent)
- What is the likelihood you would return to this professional (assuming you need future care)? (1 = Not at all likely; 10 = Extremely likely)
- How likely are you to recommend the services of this professional to your family and friends? (1 = Not at all likely; 10 = Extremely likely)
- Did the professional spend enough time with you during the visit? (1 = Not enough time at all; 10 = Adequate time)
- Did the professional listen to your explanations and questions carefully? (1 = Not carefully at all; 10 = Very acceptable)
- Did the professional answer your questions thoroughly and properly? (1 = Inadequately; 10 = Very acceptable)
- What is the degree of trust you have in this professional? (1= No trust at all; 10 = Complete trust)
- If applicable, did you receive clear printed or written information? (Yes, No, N/A)
Please feel free to add comments related to the above questions
On a scale of 1 (=worst) to 10 (=best), please rate your experience with the healthcare professional:
About the visit, facilities and staff:
- How easy was it to schedule a visit with this professional? (1 = Inadequate; 10 = Very acceptable)
- How clean was the medical office in general? (1 = Inadequate; 10 = Very acceptable)
- How would you rate the parking experience? (1 = Inadequate; 10 = Very acceptable)
- How would you rate the medical staff friendliness? (1 = Inadequate; 10 = Very acceptable)
- How would you rate the medical staff effectiveness? (1 = Inadequate; 10 = Very acceptable)
- How would you rate the medical staff behavior when the doctor was not present? (1 = Inadequate; 10 = Very acceptable)
Please feel free to add comments related to the above questions
- Please enter in the box how many minutes (approximately) you spent with this health professional during this visit.
- Please enter in the box how many minutes (approximately) you had to wait to see this health professional.
General comments about the health professional:
- Please enter in the box below what you believe this professional should CONTINUE DOING.
- Please enter in the box below what you believe this professional should STOP DOING.
- Please enter in the box below what you believe this professional should START DOING.
General comments about the medical office and staff:
- Please enter below any additional comments you would like to share with this professional (remember that your responses are anonymous unless you mention your name).
Patient information:
- Optional responses to: date of birth, sex, date of visit, time of day of the visit, family income, educational level, race/ethnic.
Patient contact information (optional and used only for the purpose of notifying the prize drawing winner):
- Complete name, complete address, phone number, alternative phone number, email address, confirm email address.
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