Advantage Health Center Patient Satisfaction Survey
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1Today’s date:
____/_____/____
Patient Satisfaction Survey
We welcome your feedback!
Please rate our staff & operations based on your experience today!
Patient’s Age _________
Is this your first visit to an Advantage Health Center site?
Yes
No
Patient’s Sex:
Female
Male
If No, how long have you been an AHC patient?
less than 1 year
2-5 years
5+ years
Service(s) received today?
(Check all that apply)
Which AHC site do you receive health care at?
Medical
Social Work
Pediatric
Other______
Advantage Family Hlth Ctr
Thea Bowman Hlth Ctr
Childrens’ Health Center
Waller Health Ctr
Very
Registration
Poor Fair Good
Good Excellent
A
(circle ONE choice 1 - 5)
1
Friendliness/courtesy of the person at the registration desk
1
2
3
4
5
2
Ease of getting an appointment when you wanted
1
2
3
4
5
3
Ease of the registration process
1
2
3
4
5
4
Acceptable time in registration/waiting room area
1
2
3
4
5
5
Time to complete check out and schedule next appointment
1
2
3
4
5
Comments (describe good and bad experiences)
Very
Providers and Support Staff (
)
Poor Fair Good
Good Excellent
B
circle ONE choice 1 - 5
1
Friendliness/courtesy of the support staff
1
2
3
4
5
2
Friendliness/courtesy of the Doctor/Nurse
1
2
3
4
5
3
Your understanding of your health care treatment plan
1
2
3
4
5
4
Your comfort with asking questions
1
2
3
4
5
5
Your understanding of prescribed medications
1
2
3
4
5
6
Your understanding of when & why you need to have a return
1
2
3
4
5
visit
7
Time spent waiting in the examination room
1
2
3
4
5
8
If appropriate, you received referral services for additional tests
1
2
3
4
5
or other health care needs such as specialists, x-rays, lab tests,
etc.
Comments (describe good and bad experiences)
Very
Overall Assessment
Poor Fair Good
Good Excellent
C
(circle ONE choice 1 - 5)
1
How well the staff worked together to provide care
1
2
3
4
5
2
Staff treated me with dignity and respect
1
2
3
4
5
3
Overall rating of care received during your visit
1
2
3
4
5
4
Likelihood of your recommending our services to others
1
2
3
4
5
5
Degree to which our services met your expectations
1
2
3
4
5
Comments (describe good and bad experiences)
□ NO
□YES
Will you return for services at our health center?
General Comments/Suggestions:
Thank you! Please return to front desk staff.
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Parent category: Life