Patient Experience Survey

Welcome to the E-Trax Patient Experience Survey. This survey is in regard to your most recent visit with Dr. .

When you are finished with your survey, be sure to click the SUBMIT COMPLETED SURVEY button at the bottom of the last page. Your input will not be included until you click this button.

Please use the 6 point satisfaction rating scale below for Questions 1 thru 6

1 2 3 4 5 6 N Highly dissatisfied Dissatisfied Somewhat dissatisfied Somewhat satisfied Satisfied Highly satisfied Not applicable

	During this visit, how SATISFIED were you with the following services?	Highly Dissatisfied 1	Dissatisfied 2	Somewhat dissatisfied 3	Somewhat satisfied 4	Satisfied 5	Highly Satisfied 6	Not Applicable N
1	The sign-in process
2	The timeliness of all services
3	The way information was shared with you
4	The way information was shared with your loved ones
5	The overall care given by the staff
6	The overall care given by the doctor

	Please use the 6 point agreement rating scale below for Questions 7 thru 23

1 2 3 4 5 6 N Strongly disagree Disagree Somewhat disagree Somewhat agree Agree Strongly agree Not applicable

	How much do you AGREE with the following statements?	Strongly disagree 1	Disagree 2	Somewhat disagree 3	Somewhat agree 4	Agree 5	Strongly agree 6	Not Applicable N
7	The Doctor treated me with respect
8	All the doctors on my team followed the same plan of care
9	The doctor listened to me
10	All of the doctors worked together on my case
11	The doctor seemed to care about my feelings
12	I was given help to deal with pain
13	The doctor and staff worked well as a team
14	The doctor told me all I needed to know
15	I felt my loved ones were involved in decisions about my care
16	The staff helped me when I needed help
17	I felt comfortable asking questions
18	I was asked about decisions that were made about my care
19	I was kept comfortable
20	My loved ones were told how to help after I left the office or hospital
21	I understand my treatment
22	I know what to do after I leave the office or hospital
23	I know who to call if I have questions

Please answer Yes or No for questions 24 and 25:		Yes	No
24	I would recommend this doctor to my loved ones
25	I would recommend this office or hospital to my loved ones

	Please give us your comments for Q26 &27:

26	What was good about your visit?

27	What could be better?
	Demographics - Optional
			Male	Female
		Gender
		Ethnicity	African American Asian Caucasian Hispanic Other Select One
		Age	Under 18 18 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 Over 90 Select range

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Submit completed survey (your feedback will be submitted and you will not be able to revise your responses)