Doctor’s Office Evaluation – Texas Surgical Association

Doctor's Office Evaluation

Patient Name:

How long have you been a patient at this office?
I’m new to the practiceLess than a year1-2 Years2-5 Years5-10 YearsTen years or more

Including this visit, how many times have you been to our practice in the past year?
12-45-10More than once a monthOnce a week or more

Where did you learn about our practice?
AdvertisementFriend/family recommendationInsuranceLocationResearchOther (Please specify)

What is the reason for your visit today?
Regular check-upHealth problemEmergency visitOther (Please specify)

Was your appointment at a time that fit well with your schedule?
YesNo

How long was the wait between your appointment time and actually seeing the doctor?
Less than 5 minutes5-10 minutes10-20 minutes20-30 minutes30-40 minutesMore than 1 hour

Please rate your level of agreement with the following statements:

The office appeared well maintained.