Office/Clinic Survey example

This is an example Office/Clinic Survey survey. This survey includes questions like:

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1) Did you have an appointment?
  • Yes
  • No

Please tell us how satisfied or dissatisfied you were with each of the following:

2) How satisfied were you with the way you were treated by the staff at our office?
  • Very Satisfied
  • Somewhat Satisfied
  • Undecided
  • Somewhat Dissatisfied
  • Very Dissatisfied
3) How satisfied were you with the way you were treated by the nurse?
  • Very Satisfied
  • Somewhat Satisfied
  • Undecided
  • Somewhat Dissatisfied
  • Very Dissatisfied
4) The doctor?
  • Very Satisfied
  • Somewhat Satisfied
  • Undecided
  • Somewhat Dissatisfied
  • Very Dissatisfied
5) The amount of time the doctor spent with you?
  • Very Satisfied
  • Somewhat Satisfied
  • Undecided
  • Somewhat Dissatisfied
  • Very Dissatisfied

Please tell us how much you agree or disagree with the following statements:

6) The nurse was knowledgeable.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
7) The doctor was knowledgeable.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
8) The doctor was friendly and courteous.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
9) I was given complete attention by the doctor.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
10) Overall, would you say your visit to our office was very positive, somewhat positive, somewhat negative or very negative?
  • Very Positive
  • Somewhat Positive
  • Undecided
  • Somewhat Negative
  • Very Negative
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