Brevard Physicians Network: Patient Survey

Patient Survey:

You would provide us with valuable information if you took the opportunity to fill out this short survey about your practice experience. Our physicians are very interested in improving the patient experience, your anonymous input will help.

Patient Demographics:
Male Female
Age Group:
Type of coverage: Medicare HMO Medicaid Group Health Plan
Actual Survey:
1. What was the purpose of your office visit:
Well visit Emergency Follow up Other
2. Do you have an appointment ?
Yes No.
3. If you did not have an appointment how long did it take to you to get one?

4. How long did it take for you to be seen by the doctor?

Please tell how satisfied or dissatisfied you were with the following:
5. How satisfied were you with the way you were treated by the office staff:
Very Satisfied Somewhat Satisfied Undecided Somewhat Undecided Very Dissatisfied
6. How satisfied were you with the way you were treated by the nurse?
Very Satisfied Somewhat Satisfied Undecided Somewhat Undecided Very Dissatisfied
7. How satisfied were you with the way you were treated by the doctor?
Very Satisfied Somewhat Satisfied Undecided Somewhat Undecided Very Dissatisfied
8. How satisfied were you with the amount of time the doctor spent with you?
Very Satisfied Somewhat Satisfied Undecided Somewhat Undecided Very Dissatisfied
9. How satisfied were you with the way each of your questions where answered ?
Very Satisfied Somewhat Satisfied Undecided Somewhat Undecided Very Dissatisfied
Please tell us how much you agree or disagree with the following statements:
10. The staff was thorough and knowledgeable:
Strongly agree Agree Undecided Disagree Strongly Disagree
11. The nurse was thorough and knowledgeable:
Strongly agree Agree Undecided Disagree Strongly Disagree
12. The nurse was friendly and courteous:
Strongly agree Agree Undecided Disagree Strongly Disagree
13. The doctor was thorough and knowledgeable:
Strongly agree Agree Undecided Disagree Strongly Disagree
14. The doctor was friendly and courteous:
Strongly agree Agree Undecided Disagree Strongly Disagree
15. My visit to the office/clinic was a pleasant experience:
Strongly agree Agree Undecided Disagree Strongly Disagree
16. Overall would you say your visit to the office was:
Very Positive Somewhat Positive Undecided Somewhat Negative Negative
17. Base on your experience would refer this physician to your friends or family members?
Yes No
18. What, if anything did you like most about your office visit?

19. What, if anything did you like least about your office visit?

20. What, if anything would you change to make your office visit more pleasant?

(321) 757-7600