How Are We Doing?

Pediatric Cardiology Patient Survey

Please complete this survey so we may improve the quality of care for our patients. However, please do not sign this fill this out unless you have previously signed a HIPAA release with us and reviewed our Notice of Privacy Practice. Thank you!

* Indicates required information

Please provide the following information to help us best serve you.

First Name *
Last Name *
Email

1. *

Month of visit:

This is my first visit:

  Yes
  No
  None

I was referred to the practice by:

	referring physician
	friend
	self
	Other
	None

If Other, please specify:

I was refered for the following services;

Instruction

Please rate the following items:

Ease of making my appointment;

	excellent
	good
	fair
	poor
	n/a
	None

Appointment available within a reasonable amount of time:

	excellent
	good
	fair
	poor
	n/a
	None

Ease of check-in and registration process

	excellent
	good
	fair
	poor
	n/a
	None

Waiting time in the reception area:

	excellent
	good
	fair
	poor
	n/a
	None

Waiting time in the exam room:

	excellent
	good
	fair
	poor
	n/a
	None

10.

Ease of getting referral:

	excellent
	good
	fair
	poor
	n/a
	None

11.

The courtesy and respect of the people I spoke with on the phone:

	excellent
	good
	fair
	poor
	n/a
	None

12.

The courtesy and respect of the nursing staff:

	excellent
	good
	fair
	poor
	n/a
	None

13.

The courtesy and respect of the care providers (physicians, nurses);

	excellent
	good
	fair
	poor
	n/a
	None

14.

The courtesy and respect of the sonographers;

	excellent
	good
	fair
	poor
	n/a
	None

15.

The helpfullness of the people in the business office;

	excellent
	good
	fair
	poor
	n/a
	None

16.

My phone calls were answered promptly:

	always
	occasionally
	sometimes
	never
	n/a
	None

17.

Availability of medical information/advice by telephone;

	excellent
	good
	fair
	poor
	n/a
	None

18.

Ability to obtain prescriptions by phone;

	excellent
	good
	fair
	poor
	n/a
	None

19.

Test results reported in a reasonable amount of time;

	excellent
	good
	fair
	poor
	n/a
	None

20.

Explanations concerning procedures and tests;

	excellent
	good
	fair
	poor
	n/a
	None

21.

Ability to contact the office after hours;

	excellent
	good
	fair
	poor
	n/a
	None

22.

Care provider listened to my questions and concerns;

	excellent
	good
	fair
	poor
	n/a
	None

23.

Care providers answered my questions;

	excellent
	good
	fair
	poor
	n/a
	None

24.

Care provider's instructions relate to my child's (or my) care or treatment;

	excellent
	good
	fair
	poor
	n/a
	None

25.

Hours of operation;

	excellent
	good
	fair
	poor
	n/a
	None

26.

Overall comfort of the office/facility;

	excellent
	good
	fair
	poor
	n/a
	None

27.

Availability of parking;

	excellent
	good
	fair
	poor
	n/a
	None

28.

Office/facility signs and directions are easy to follow;

	excellent
	good
	fair
	poor
	n/a
	None

29.

Overall satisfaction with the practice;

	excellent
	good
	fair
	poor
	n/a
	None

30.

Overall satisfaction with the quality of my medical care;

	excellent
	good
	fair
	poor
	n/a
	None

31.

I would recommend the practice to others.

  Yes
  No
  Other
  None

If Other, please specify:

32.

My office visit included;

	ultrasound only
	office visit
	counseling
	testing

33.

The provider who cared for me during my visit was;

34.

Patient's age group was:

	Newborn to 18 months
	19 months-3 years
	4-12 years
	13-18 years
	19-30 years
	31-40 years
	41-60 years
	61 years or older
	None

35.

Please use the space provided below for any additional comments.

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