Returning Patient Survey

Tell Us What You Think

Help Us to Help Others

We appreciate your feedback and look forward to hearing from you. Your comments will help us better serve you and other patients in the future. Please complete as much or as little of the survey as you feel necessary.

Return Patient Survey

Date of your visit *

Year

Month

Day

Gender *

Age group *

Did you receive a confirmation prior to your appointment? *

Which provider did you see at this appointment?

Reception

Friendliness of the reception staff

Time you waited to be checked in at the Clinic

Time you waited to be called into an exam room

Comfort of the reception waiting room

Quietness of the reception waiting room

Ease of scheduling a return appointment

Billing questions answered

Professionalism of the billing staff

You made aware of special programs, like the Advanced Personalized Program, that may be available to you?

Nursing Staff

Friendliness of the nursing staff

Time you waited in the exam room for the provider

Effectiveness of your nurse's communication skills

Professionalism of the nursing staff

Time you waited for injections, lab tests or prescriptions

Skill of the person performing any necessary lab tests

Physician Assistant (PA)

Friendliness of the PA

Quality of information provided by the PA

Did you see your physician as well as the PA

Would you schedule your follow-up visit with your physician's PA?

Satisfaction with the PA visit in comparison to a visit with your physician

Physician

Friendliness of your physician

Quality of information provided by your physician

Effectiveness of your physician's communication skills

Effectiveness of your physician's listening skills

Your physician adequately explained treatment plans, and answered your questions

Waiting time to see your physician in minutes

Phone Calls

If you called your physician's nurse, the time in which your phone call was returned

Friendliness of your physician's nurse on the phone

Knowledge level of the nurse you spoke with regarding your question

Your physician's nurse made you aware of special programs, like the Advanced Personalized Program, that may be available to you?

Did your call need to be transfered to the physician or PA for a response?

Your nurse went above and beyond to answer your question

Your PA returned the phone call in a timely manner

Friendliness of the PA on the phone

Inpatient Unit (if admitted)

Discharge/follow-up instructions were clear and appropriate

Usefulness of Biofeedback

Friendliness of nursing staff at the hospital

Knowledge level of nursing staff at the hospital

Quality of Inpatient Unit classes

Overall

Cleanliness of the Clinic

Materials and information on the Web site were easy to find

Quality of staff's cooperative effort to care for you

Likelihood of recommending the Clinic to others

Overall rating of care given to you at the Clinic

Overall rating of your Clinic experieince

Chance you will return to the Clinic for care

Medical Records (if contacted)

Friendliness of the medical records staff

Time you waited to receive your medical records

Accuracy of the records you received in relation to your request

Were you asked to sign a Release of Information form prior to your records being released?

Free Form Questions

What did we do best?

Additional comments

How could we improve?

Would you like someone from the Clinic to contact you regarding your visit?

If so, your name please

*Diamond Headache Clinic’s goal is to rehabilitate, restore and improve function and independence, as well as to reduce the effects of the condition. Results may differ and no claims, promises or guarantees are being made or implied about the average, typical or expected results.