Contact Information

General Patient Information

What zip code do you live in?

33040 33042 33043 33050 33001 33036 33070 33037 Others:

Which clinic did you visit?

Lower Keys/Key West Middle Keys/Marathon Upper Keys

How did you hear about our services?

Referral from an agency Referral from a friend or family Newspaper ad Television ad Radio ad Brochure Others :

Patient is what age?

Under 18 18-34 35-49 50-64 Over 65

Patient is what sex?

Male Female

What is patient’s race or ethnicity?

White (Caucasian) Black (Afro-American) Hispanic Asian American Indian Others :

Do you own or rent your residence?

Own Rent Homeless

Do you live in Public housing?

Yes No

What is the TOTAL annual income for all members of your household, before taxes?

Under $ 10,000 $10,000- $19,999 $20,000- $29,999 $30,000- $39,999 $40,000- $49,999 $50,000- $59,999 $60,000- $69,999 $70,000- $79,000 $80,000- $99,999 Over $100,000

What is your current employment status?

Employed full time Employed full time plus a part time job Employed part time only Unemployed & not collecting unemployment Unemployed and collecting unemployment benefits Retired- not working Student- not working On Disability only On Worker’s Compensation-only Others :

What type of health insurance do you have?

Medical only Dental only Medical & Dental Catastrophic insurance only with very high deductable (over $5,000/yr) None

Where did you previously go for your health care needs prior to visiting us?

Private practice doctor or dentist Hospital ER Others :

In general, what is the quality of your health?

Outstanding Good Some chronic issues Poor

How often have you visited a dentist in the past year?

First visit in past 12 months 2-3 visits in past 12 months More than 4 visits in past 12 months N/A

How often have you visited a doctor in the past year?

First visit in past 12 months 2-5 visits in past 12 months More than 6 visits in past 12 months N/A

Scheduling Your Appointment

Did you Schedule an appointment by phone or did you drop in?

Scheduled by phone Scheduled by dropping in Walk-in, with no appointment

If you scheduled an appointment, did you have to wait longer that expected to get scheduled?

Yes No

How easy was it to make an appointment by telephone?

Very easy Easy Just OK Not so easy Very Difficult

How long did you wait to speak to a scheduling staff member?

0-2 minutes 3-5 minutes 6-7 minutes Longer

Was the person who scheduled your appointment courteous and helpful?

Very courteous Courteous Just OK Rude Very Rude

If you were seeking a referral to a specialist, were you request handled in a timely manner?

Yes No

Day of Your Appointment

How would you rate the courtesy of the staff at the reception desk?

Very courteous Courteous Just OK Rude Very Rude

How long did you wait in the reception area beyond your scheduled appointment time?

0-5 minutes 6-20 minutes 20-40 minutes Others : Minutes

How long did you wait in the exam room before you were seen by the doctor/dentist/other professional?

0-5 minutes 6-20 minutes 20-40 minutes Others : Minutes

If dental, which department(s) did you visit during your appointment?

Hygiene for cleaning Dental exam only Dental extraction Dental filling N/A Others :

If medical, which department(s) did you visit during your appointment?

General Practitioner Walk-in / Urgent Care Pediatrics Women´s Health Men´ Health Counseling and/or therapy N/A

What do you feel was the demeanor of your doctor/dentist?

Attentive Concerned Friendly Distracted Rushed Inconsiderate

How would you rate the competence of your doctor/dentist?

Outstanding Good Adequate Needs Improvement Poor N/A

Did you feel that your examination was thorough?

Yes No N/A

Please rate the clarity of the doctor’s/dentist’s explanation of your condition and treatment options:

Outstanding Good Adequate Needs Improvement Poor N/A

How well were you included in your healthcare decisions?

Outstanding Good Adequate Needs Improvement Poor N/A

Were your questions answered to your satisfaction?

Yes No N/A

Would you recommend this facility and its staff to your family and friends?

Yes No N/A

Medical Patients only: Dental Patients please skip this section…

How would you rate the professionalism of the person who took your blood and worked on your lab exam?

Outstanding Good Adequate Needs Improvement Poor N/A

If you received a lab exam, please indicate the type(s) if lab exam you received:

Blood test Breast exam Pap Smear / cervical exam Prostate exam / test CT scan MRI X-ray N/A Others :

If you received a lab exam, was the service prompt, comfortable, and courteous?

Outstanding Good Adequate Needs Improvement Poor N/A

Personal Information

Name Email * Address City State Zip Code Telephone Number

Would you like someone to contact you regarding your responses on this survey?

Yes No

Has your visits to the clinics increased your knowledge base in relation to your treatment?

Yes No

Would you like to write something about what you learned?

Yes No

How would you rate the survey overall, on a scale of 1-10; 1 being very poor & 10 being excellent?
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