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Physician visited:*

Today's visit is mainly for:

Based on the MOST RECENT VISIT to you doctor

1. Your doctor adequately explained your treatment choices.

Based on ALL YOUR VISITS to your doctor’s office, how do you feel about your doctor’s attitude and behavior towards you? My doctor:

2. Spends enough time with me and shows interest in my problems.

3. Asks details about my personal life, when appropriate

4. Answers my questions well regarding my office visit.

How do you feel that your doctor runs his or her practice?

5. Telephone, It is easy to reach the office by phone during the day.

6. The Staff, Is helpful and pleasant

7. The Staff, Is respectful of patients and behaves in a professional manner

8. Office Practices, I can get an appointment quickly

9. Office Practice, My doctor's office follows-up on any serious problems I may have

10. General, My physician talks to me about preventative care (e.g. quitting smoking, weight control, sleeping, alcohol, exercise, etc.)

11. General, I would go back to this doctor

11. General, I would send a friend to this doctor

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