Patient Survey

Dear Patient,

Your opinions and perceptions about the care you receive from me are important. I would like to know how you feel about the medical services, our communications with you and our staff members.

Please take a few minutes of your time to help me by answering the following questions.  All of your individual responses will be kept strictly confidential. Thank you in advance for your help.

Sincerely,

Arati M. Dunbar, M.D.

On a scale of 1 - 5 with 5 being excellent and 1 being poor, please rate each item by circling the appropriate number. If an item is not applicable, please circle not applicable (NA).

We welcome your comments.

		Rating Scale	Comments
1	Scheduling of appointments for:
	New patient, first visit	1 2 3 4 5 NA
	Follow up visits	1 2 3 4 5 NA
	Second opinion appointments	1 2 3 4 5 NA
	X-rays	1 2 3 4 5 NA
2	The amount of time you have to wait:
	For your appointment	1 2 3 4 5 NA
	For response to telephone calls by office staff	1 2 3 4 5 NA
	For response to telephone calls by physician	1 2 3 4 5 NA
	For response to billing and insurance questions	1 2 3 4 5 NA
3	Obtaining information on:
	Medical diagnosis	1 2 3 4 5 NA
	Treatment	1 2 3 4 5 NA
4	Your office visit:
	Office location	1 2 3 4 5 NA
	Temperature of the exam room	1 2 3 4 5 NA
	Comfort of the waiting room and exam room	1 2 3 4 5 NA
5	Your impression of Dr. Dunbar:
	Knowledge of medicine	1 2 3 4 5 NA
	Care provided to you	1 2 3 4 5 NA
	Explanation of procedures or results	1 2 3 4 5 NA
	Concern for your comfort	1 2 3 4 5 NA
	Answers to medical questions on your condition	1 2 3 4 5 NA
	Answers to medical questions on your treatment plan	1 2 3 4 5 NA
6	Your impression of the staff
	Care provided to you	1 2 3 4 5 NA
	Explanation of procedures or results	1 2 3 4 5 NA
	Concern for your comfort	1 2 3 4 5 NA
	Answers to your questions	1 2 3 4 5 NA
7	Do you feel the fees charged are reasonable in relation to the services provided?	Yes No
8	How were you first referred to our office?	Select one ... Friend/family member Physician referral Yellow pages advertising Newspaper advertising Recommended by the hospital Other
9	Would you recommend us to a family member or friend?	Yes No	If no, please tell us why?
10	Is there anything that we could change to make your visit more comfortable for you?
The following information is optional but desirable
11	We would appreciate some information about you.
	Age
	Home zip code
	Your type of health insurance
If you would like a response to this questionnaire please give us your name, address and telephone number.
	Name
	Address
	City
	State
	Zip Code
	Telephone Number
	E-Mail Address