1. How likely is it that you would recommend your provider to a friend or family member?* 0 1 2 3 4 5 6 7 8 9 10 2. Overall, how satisfied or dissatisfied were you with your last visit to our Clinic?* Very Satisfied Somewhat dissatisfied Somewhat satisfied Very dissatisfied Neither satisfied nor dissatisfied 3. How easy or difficult was it to schedule your appointment at a time that was convenient for you?* Very easy Somewhat difficult Somewhat easy Very difficult Neither easy nor difficult 4. How convenient was the appointment time you were able to get?* Extremely convenient Not so convenient Very convenient Not at all convenient Somewhat convenient 5. In your opinion, how convenient is the location of our Clinic?* Extremely convenient Not so convenient Very convenient Not at all convenient Somewhat convenient 6. Overall, how would you rate the service you received from the staff at our clinic?* Excellent Fair Very good Poor Good 7. How comfortable was the lobby and waiting area?* Extremely comfortable Not so comfortable Very comfortable Not at all comfortable Somewhat comfortable 8. Did your appointment with your provider start early, late or on time?* Very early Somewhat late Somewhat early Very late On time 9. Overall, how would you rate the care you received from your provider?* Excellent Fair Very good Poor Good 10. How much do you trust your provider to make medical decisions that are in your best interests?* A great deal A little A lot Not at all A moderate amount 11. How well did your provider listen to your needs?* Extremely well Not so well Very well Not at all well Somewhat well 12. How well did your provider answer your questions?* Extremely well Not so well Very well Not at all well Somewhat well 13. How well did your provider explain your treatment options?* Extremely well Not so well Very well Not at all well Somewhat well 14. How well did your provider explain your follow-up care?* Extremely well Not so well Very well Not at all well Somewhat well 15. How satisfied or dissatisfied were you with the amount of time your provider spent with you addressing your needs?* Very satisfied Somewhat dissatisfied Somewhat satisfied Very dissatisfied Neither satisfied nor dissatisfied 16. Is there anything we could have done to improve your last visit?*