1. Were you able to make an appointment easily?

2. Was the person who made your appointment courteous and helpful?

3. Personal interest shown in you/the patient's medical problems:

4. The provider’s ability to answer questions in a way you/the patient could understand:

5. Explanations of medical procedures and tests:

6. Adequacy of information and education received during the visit:

7. Overall rating of the provider seen during the visit:

8. Overall, how would you rate the care received at the office visit:

9. Overall satisfaction with the visit:

10. Based on today’s visit, would you schedule the next appointment with this provider:

11. Quality of patient education materials

12. Ability to obtain referrals to other services as needed (e.g. social worker, nutritionist)

13. Quality of follow-up evaluation and education