Survey Form

Required Optional Completed

Choose Location

Choose Physician

Personal Details

Your Name

Your Email

Your Phone Number

Relationship to Patient

Question 1 out of 34

Patients age =>

Question 2 out of 34

Patient Gender =>

Male

Female

Question 3 out of 34

Patients Ethnicity =>

Hispanic or Latino

Not Hispanic or Latino

Refused

Question 4 out of 34

What kind of Insurance do you have?

Commercial

Medicaid Medicare

Selfpay

Refused

Question 5 out of 34

Were you able to reach our staff when you called us?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 6 out of 34

The time between your call to schedule an appointment and the day of your appointment.

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 7 out of 34

Our Same day appointment/Office hours meet your needs?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 8 out of 34

The helpfulness and professionalism of our staff over the phone?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 9 out of 34

Did you need a Saturday Appointment? Were you able to get it?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 10 out of 34

Did you need a Same day Saturday Appointment? Were you able to get it?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 11 out of 34

The comfort, cleanliness and amenities of the reception area.

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 12 out of 34

Friendliness and courtesy of care providers.

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 13 out of 34

Did your physician and her team answer all of your questions?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 14 out of 34

Explanations the care provider gave you about your problems or concerns.

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 15 out of 34

Amount of time the care provider spent with you.

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 16 out of 34

Information the care provider gave you about the medication (if any)

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 17 out of 34

Your confidence in your Care Team.

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 18 out of 34

How likely would you recommend this care provider to others?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 19 out of 34

Your overall visit in the office

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 20 out of 34

Were you able to get in contact with Powers Pediatrics after normal business hours?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 21 out of 34

Did the physician and her team listen to your question/comments without interrupting?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 22 out of 34

Did you get the answer of your concerns/questions when you called the office after hours?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 23 out of 34

Was it helpful to you that your concerns/questions were addressed after hours?

Completely Satisfied

Somewhat Satisfied

Satisfied

Somewhat Unsatisfied

Completely Unsatisfied

Question 24 out of 34

How many times has the patient ended up in the E.R or urgent care center?

0

1-5

5+

Question 25 out of 34

Did Powers Pediatrics call you to remind you about your appointment next day?

Yes

No

N\/A

Question 26 out of 34

Did Powers Pediatrics call you to inform you about your recent lab results?

Yes

No

N\/A

Question 27 out of 34

Did Powers Pediatrics call you to schedule an appointment about your recent lab results?

Yes

No

N\/A

Question 28 out of 34

Did the specialist that we referred to you addresses your concerns?

Yes

No

N\/A

Question 29 out of 34

Do you have access to patient portal (where you can view/download your health record?

Yes

No

N\/A

Question 30 out of 34

Are you and your children eating healthy?

Yes

No

N\/A

Question 31 out of 34

Did you know Powes Pediatrics offers Telemedicine?

Yes

No

N\/A

Question 32 out of 34

Were you able to get access to powers pediatrics via Telemedicine?

Yes

No

N\/A

Question 33 out of 34

How did you schedule your appointment?

Office

Phone

Online

Walk-In

Question 34 out of 34

test

1

2

3

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