Hightstown Medical Associates

Patient Satisfaction Survey

We appreciate your assistance as we try to improve our service. Please complete the form below to the extent that you can. We will use this information to identify our weaknesses and work to improve them. No attempt will be made to identify you. The data will be reported back to the office in aggregate only. Please accept our thanks in advance for your help with this project. You may enter comments at the end.

		Excellent	Very Good	Good	Fair	Poor	Does Not Apply
When I called the office for an appointment, the length of time before the phone was answered was:
I waited minutes before someone answered the phone.
The length of time I spent on the phone to set my appointment was:

The number of days between my call and my actual appointment was:
The staff's helpfulness in scheduling my appointment was:

The convenience of the office hours was:
The staff's courtesy was:

The staff's promptness and efficiency were:
The length of time, if any, that I had to wait past my appointment time was:

The staff's effort to explain the reason for any delay was:
The nurse/medical assistant's skill when taking my weight, temperature, blood pressure, blood sample, etc. was:

The clarity and thoroughness of the nurse/medical assistant's instructions were:
The nurse/medical assistant's care was:

		Excellent	Very Good	Good	Fair	Poor	Does Not Apply
The length of time I had to wait in the examination room before I saw the Doctor was:
I waited minutes beyond my appointment time before seeing the physician.
The doctor's effort to make me feel at ease was:

The doctor's understanding of the reason for my visit was:
The doctor's interest in my overall health was:

The doctor's skill in examining me was:
The doctor's thoroughness in examining me was:

The doctor's explanation of each step of the examination was:
The doctor's explanation of my diagnosis was:

The doctor's encouragement for me to ask questions was:
The doctor's responses to my questions were:

The clarity and thoroughness of the doctor's discussion with me about treatment options was:
The doctor's explanation of why I needed my tests was:

		Excellent	Very Good	Good	Fair	Poor	Does Not Apply
The staff's explanation of when and how I would hear about any test results was:
The doctor's instructions (oral/written) about any prescription drugs were:

The doctor's reassurance about my diagnosis and treatment was:
The doctor's encouragement to call if I had any problems or questions was:

The length of time my doctor spent with me was:
The staff's help with scheduling any follow-up visits, referrals or tests was:

The staff's explanation of billing and payment/insurance issues was:
The staff's respect for my privacy was:

The doctor's ability to meet my needs was:
My overall satisfaction with the quality of care I received during this visit was:

My willingness to recommend this physician and practice to a close friend or family member is:
Overall, my health is:

The primary reason for my visit today was:	for a regular check-up, well-person examination, physical to get help for a specific acute problem or illness (infection, strain, etc.) for chronic disease management (asthma, diabetes, blood pressure, etc.)

Demographics:
Age:	<18 18-34 35-54 55-64 65+

Gender:	Male Female

Insurance:	Medicare HMO/POS PPO None/Self-pay

Education:	High School or less Technical School, Associate Degree or some college work College Degree Professional or Graduate Degree

What was the date of your visit?

Which provider did you see?

Please enter any other comments you have regarding our practice or your experience with us.

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