Methodist Occupational Health & Wellness Patient Survey

Please complete this brief, confidential survey. Your responses will help us validate or improve our services.

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* 1. When were you seen in our Occupational Medicine clinic?

Date:

Date

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* 2. Which location did you visit?

Ankeny

Des Moines

West Des Moines

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* 3. What service did you receive?
Please check all that apply.

Injury care - first visit

Injury care - recheck

Pre-employment physical

DOT physical exam

Drug screen

Breath alcohol test

Immunization or lab work

Other exam or service (please specify):

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* 4. How many minutes did you wait in the lobby?

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* 5. If you saw a provider, how many minutes did you wait in the exam room before he/she arrived?

Please rate your experience in each of the following areas.
If anything does not apply, select N/A for "Not Applicable".

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* 6. Experience with clinic staff:

	Very Good	Good	Neutral	Bad	Very Bad	N/A
Friendliness and helpfulness of front desk	Friendliness and helpfulness of front desk Very Good	Friendliness and helpfulness of front desk Good	Friendliness and helpfulness of front desk Neutral	Friendliness and helpfulness of front desk Bad	Friendliness and helpfulness of front desk Very Bad	Friendliness and helpfulness of front desk N/A
Professionalism and skill of nurses	Professionalism and skill of nurses Very Good	Professionalism and skill of nurses Good	Professionalism and skill of nurses Neutral	Professionalism and skill of nurses Bad	Professionalism and skill of nurses Very Bad	Professionalism and skill of nurses N/A
Response to your questions or concerns	Response to your questions or concerns Very Good	Response to your questions or concerns Good	Response to your questions or concerns Neutral	Response to your questions or concerns Bad	Response to your questions or concerns Very Bad	Response to your questions or concerns N/A
Respect of your privacy	Respect of your privacy Very Good	Respect of your privacy Good	Respect of your privacy Neutral	Respect of your privacy Bad	Respect of your privacy Very Bad	Respect of your privacy N/A
Overall attentiveness and attitude	Overall attentiveness and attitude Very Good	Overall attentiveness and attitude Good	Overall attentiveness and attitude Neutral	Overall attentiveness and attitude Bad	Overall attentiveness and attitude Very Bad	Overall attentiveness and attitude N/A

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* 7. Experience with the provider (if applicable):

	Very Good	Good	Neutral	Bad	Very Bad	N/A
Responsiveness to your problem or pain	Responsiveness to your problem or pain Very Good	Responsiveness to your problem or pain Good	Responsiveness to your problem or pain Neutral	Responsiveness to your problem or pain Bad	Responsiveness to your problem or pain Very Bad	Responsiveness to your problem or pain N/A
Explanation of procedures, diagnosis and treatment	Explanation of procedures, diagnosis and treatment Very Good	Explanation of procedures, diagnosis and treatment Good	Explanation of procedures, diagnosis and treatment Neutral	Explanation of procedures, diagnosis and treatment Bad	Explanation of procedures, diagnosis and treatment Very Bad	Explanation of procedures, diagnosis and treatment N/A
Explanation of medications or equipment	Explanation of medications or equipment Very Good	Explanation of medications or equipment Good	Explanation of medications or equipment Neutral	Explanation of medications or equipment Bad	Explanation of medications or equipment Very Bad	Explanation of medications or equipment N/A
Explanation of work restrictions, if any	Explanation of work restrictions, if any Very Good	Explanation of work restrictions, if any Good	Explanation of work restrictions, if any Neutral	Explanation of work restrictions, if any Bad	Explanation of work restrictions, if any Very Bad	Explanation of work restrictions, if any N/A

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* 8. Overall, how well did our staff work together to provide your service?

Very Good

Good

Neutral

Bad

Very Bad

N/A

Very Good

Good

Neutral

Bad

Very Bad

N/A

About You (optional):

Question Title

* 9. Gender:

Male

Female

Methodist Occupational Health & Wellness Patient Survey

Question Title

* 1. When were you seen in our Occupational Medicine clinic?

Question Title

* 2. Which location did you visit?

Question Title

* 3. What service did you receive?
Please check all that apply.

Question Title

* 4. How many minutes did you wait in the lobby?

Question Title

* 5. If you saw a provider, how many minutes did you wait in the exam room before he/she arrived?

Question Title

* 6. Experience with clinic staff:

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* 7. Experience with the provider (if applicable):

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* 8. Overall, how well did our staff work together to provide your service?

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* 9. Gender:

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* 10. Age:

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* 11. Your Name:

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* 12. Your Employer:

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* 13. Additional comments about your clinic visit:

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* 1. When were you seen in our Occupational Medicine clinic?

Question Title

* 2. Which location did you visit?

Question Title

* 3. What service did you receive? Please check all that apply.

Question Title

* 4. How many minutes did you wait in the lobby?

Question Title

* 5. If you saw a provider, how many minutes did you wait in the exam room before he/she arrived?

Question Title

* 6. Experience with clinic staff:

Question Title

* 7. Experience with the provider (if applicable):

Question Title

* 8. Overall, how well did our staff work together to provide your service?

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* 9. Gender:

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* 10. Age:

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* 11. Your Name:

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* 12. Your Employer:

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* 13. Additional comments about your clinic visit:

* 3. What service did you receive?
Please check all that apply.