FEEDBACK REACH USOUR PAST REVIEWS Gender :MaleFemaleAge :25 or under26-3435-4445-5455-6465 and overPlease select an age rangePhysician or facility visitedOver the last five years, how often have you seen this doctor?Once2-3 TimesOver 3 TimesToday's visit is mainly for :New ConcernOngoing ConcernExaminationBased on the MOST RECENT VISIT to your doctor1. Your doctor adequately explained your treatment choices.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UABased on ALL YOUR VISITS to your doctor's office, how do you feel about your doctor's attitude and behavior towards you? My doctor:2. Spends enough time with me and shows interest in my problems.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UA3. Asks details about my personal life, when appropriateStrongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UA4. Answers my questions well regarding my office visit.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UAHow do you feel that your doctor runs his or her practice?Telephone5. It is easy to reach the office by phone during the day.Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UAStaff6. Is helpful and pleasantStrongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UA7. Is respectful of patients and behaves in a professional mannerStrongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UAOffice Practices8. I can get an appointment quicklyStrongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UA9. Someone from my doctor's office follows-up on any serious problems I may haveStrongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UAGeneral10. My physician talks to me about preventative care (e.g. quitting smoking, weight control, sleeping, alcohol, exercise, etc.)Strongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UA11. I would go back to this doctorStrongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UA12. I would send a friend to this doctorStrongly DisagreeDisagreeNeutralAgreeStrongly AgreeUnable to Assess UASUBMIT
