Bellingham Breast Center
Patient Satisfaction Survey - Follow-up Questionnaire
For each of the following statements,
enter a number from 1-5 which states how important the item is for you,
1 being LEAST important and 5 being MOST important.
Enter only one number for each line please.A. Regarding my office interactions, grade us using a 1-5 scale: (1 LEAST to 5 MOST)
The office staff greeted me in a friendly unrushed manner
The office staff had my medical records ready for my appointment
The office staff notified me of my scheduled appointment in this office
The office staff arranged appointments that were suggested by the doctor
The office staff wrote down all my appointments and gave them to me
The office staff notified me if the doctor was running late
The office staff kept my medical records confidential
The office staff returned my phone calls
The office billing staff was courteous when calling regarding my bill
The office billing staff took care of billing my insurance compan
B. Regarding doctor interactions, grade us using a 1-5 scale: (1 LEAST to 5 MOST)
The doctor had my medical records necessary for my medical problem
The doctor listened to my history regarding my medical problem
The doctor listened to my concerns and questions about my medical problem
The doctor examined me in a medically thorough manner
The doctor saw me on time, close to my scheduled appointment time
The doctor showed me where any medical abnormality was located on my body
The doctor explains what my medical problem is in language I can understand
The doctor made me comfortable when I asked questions
The doctor explained what medical options existed for treatment of my problem
The doctor told me what his first choice recommendation is for my treatment
The doctor allowed me to make the final decision in choosing treatment for my proble
The doctor accepted my choice of treatment even if it wasn't his first choice
The doctor made me comfortable in making my choice of treatment
The doctor explained the next steps prior to leaving my appointment
C. Measures of Distress: Using a scale from 1 (the least) to 10 (the most)
Often when an acute medical problem arises, multiple emotions are experienced and it is
prudent to recognize these feelings. Distress can be the feelings of concern, worry, anxiety,
fear, nervousness, unease, apprehension, or even panic. We'd like you to score your level
of distress AFTER YOUR 1st VISIT on a scale from 1 (the least) to 10 (the most).
Thank you! Bellingham Breast Center
