Patient Surveys New PatientsReturning Patients New Patient SurveyDate of your visit* MM slash DD slash YYYY GenderMaleFemaleDecline to specifyDid you receive a confirmation prior to your appointment?YesNoNot sureWhat provider did you see for your appointment?*Dr. Merle DiamondDr. George UrbanDr. Christopher RhyneNew Patient RegistrationWas the registration staff friendly during the scheduling process?YesNoDecline to answerWere you offered different available appointment times to meet your scheduling needs?YesNoDecline to answerWere your benefits were verified and explained to you in a timely manner?YesNoDecline to answerWas the new patient information packet was helpful?YesNoDecline to answerReceptionWas the reception staff friendly?YesNoDecline to answerUpon arrival, how long did you want to be checked in by a receptionist?No wait10 minutesOver 15 minutesAfter check in, how long did you wait to be called into an exam room?0-5 minutes10-15 minutesOver 20 minutesWas the reception waiting room quiet?YesNoDecline to answerAfter your visit were you able to schedule a follow up appointment?YesNoDecline to answerNursing StaffWas the nursing staff friendly?YesNoDecline to answerHow long did you want in the exam room until a provider came in?No wait5-10 minutesover 15 minutesDid the nursing staff answer all of your questions?YesNoDeclined to answerWas the nursing staff professional?YesNoDecline to answerIf necessary, were all procedures and labs explained to you?YesNoDecline to answerAdvance PractitionerWas the Advance Practitioner friendly?YesNoDecline to answerWas all of the information the Advance Practitioner explained to you easy to understand?YesNoDecline to answerWould you schedule your follow-up visit with your physician's Advance Practitioner?YesNoDecline to answerPhysicianWas the physician friendly?YesNoDecline to answerWas the information provided by your physician easy to understand?YesNoDeclined to answerDid your physician communication everything to you thoroughly?YesNoDecline to answerDo you feel the physician's listened and addressed all of your concerns?YesNoDecline to answerWere all of your expectations for this office visit were met?YesNoDecline to answerIf no, please explainInpatient Unit (if admitted)Were the discharge/follow-up instructions were clear and appropriate?YesNoDecline to answerWas the hospital staff friendly during your stay?YesNoDecline to answerWas the nursing staff at the hospital knowledgeable?YesNoDecline to answerDid you find the Inpatient Unit classes helpful?YesNoDecline to answerOverallWas the clinic clean?YesNoDecline to answerWere materials and information on the website were easy to find?YesNoDeclined to answerWould you recommend Diamond Headache Clinic to others?YesNoDeclined to answerOverall rating of your Clinic experienceVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedWill you return to the clinic for care?YesNoDecline to answerDid staff go above and beyond for you at this visit?YesNoDecline to answerIf yes, please tell us who.Free Form QuestionsWhat did we do best?How could we improve?Would you like someone from the Clinic to contact you regarding your visit?YesNoIf so, please provide your name please and contact number.CAPTCHA Return Patient SurveyName First Last OptionalDid you receive a confirmation prior to your appointment?*YesNoDecline to answerWhat provider did you see?*Merle Diamond, MDGeorge Urban, MDChristopher Rhyne, MDLindsay Sloan, PAJessica Horwitz, NPJennifer DelMonaco, PAAlana Cheplowitz, PAHow satisfied were you with the friendliness of the reception staff?*Very SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedHow satisfied were you with the time you waited to be checked in at the Clinic?Very SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedHow satisfied were you with the time you waited to be called into an exam room?Very SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedQuietness of the reception waiting roomVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedEase of scheduling a return appointmentVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedBilling questions answeredVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedProfessionalism of the billing staffVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedNursing StaffFriendliness of the nursing staffVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedTime you waited in the exam room for the providerVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedEffectiveness of the nursing staff's communication skillsVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedProfessionalism of the nursing staffVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedAdvanced PractitionersFriendliness of the Advanced PractitionerVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedQuality of information provided by the Advanced PractitionerVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedDid you see your physician as well as the Advanced Practitioner?YesNoDecline to answerSatisfaction with the Advanced Practitioner visit in comparison to a visit with your physicianVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedWould you schedule your follow-up visit with your physician's PA?DefinitelyProbablyNot SureProbably NotDefinitely NotPhysicianFriendliness of your physicianVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedQuality of information provided by your physicianVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedEffectiveness of your physician's communication skillsVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedEffectiveness of your physician's listening skillsVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedYour physician adequately explained treatment plans, and answered your questionsVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedPhone CallsIf you called your physician's nurse, the time in which your phone call was returnedRight awayWithin 4 hoursWithin 8 hoursWithin 24 hoursWithin 48 hoursDidn't receive a call backFriendliness of your physician's nurse on the phoneVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedKnowledge level of the nurse you spoke with regarding your questionVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedYour nurse went above and beyond to answer your questionVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedYour PA returned the phone call in a timely mannerVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedFriendliness of the PA on the phoneVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedInpatient Unit (if admitted)Discharge/follow-up instructions were clear and appropriateVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedUsefulness of BiofeedbackVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedFriendliness of nursing staff at the hospitalVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedKnowledge level of nursing staff at the hospitalVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedQuality of Inpatient Unit classesVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedOverallCleanliness of the ClinicVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedMaterials and information on the Website were easy to findVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedQuality of staff's cooperative effort to care for youVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedLikelihood of recommending the Clinic to othersDefinitelyProbablyNot SureProbably NotDefinitely NotOverall rating of care given to you at the ClinicVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedOverall rating of your Clinic experienceVery SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedChance you will return to the Clinic for careDefinitelyProbablyNot SureProbably NotDefinitely NotFree Form QuestionsWhat did we do best?Additional commentsHow could we improve?Would you like to recognize a staff member who went above and beyond for you during your visit?YesNoDecline to answerWhat is the staff name?Would you like someone from the Clinic to contact you regarding your visit?YesNoDecline to answerIf so, please leave us your name and contact informationCAPTCHA
