Methodist Occupational Health & Wellness Patient Survey Please complete this brief, confidential survey. Your responses will help us validate or improve our services. Question Title * 1. When were you seen in our Occupational Medicine clinic? Date: Date Question Title * 2. Which location did you visit? Ankeny Des Moines West Des Moines Question Title * 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): 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? Please rate your experience in each of the following areas. If anything does not apply, select N/A for "Not Applicable". Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 10. Age: Question Title * 11. Your Name: Question Title * 12. Your Employer: Question Title * 13. Additional comments about your clinic visit: Thank you for your feedback! Done