Texas Pulmonary Sleep Center Hurst Patient Satisfaction Survey

In an effort to ensure quality patient care, we would appreciate your time to answer the following questions. Please be forthright and honest so that we can continue areas of strength and improve areas of weakness.

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* 1. When calling our office, was the staff friendly and helpful?

Yes

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* 2. Did you receive instructions regarding location and appt info?

Yes

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* 3. Were you notified of your financial responsibility prior to scheduling your study?

Yes

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* 4. Did you feel safe coming to our office? If No, why?

Yes

Other (please specify)

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* 5. Were you told by your physician why you were coming to our facility?

Yes

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* 6. Please rate our physical facilites based on the following, if applicable:

	Excellent	Good	Fair	Poor	N/A
Facility decor	Facility decor Excellent	Facility decor Good	Facility decor Fair	Facility decor Poor	Facility decor N/A
Restroom facilities	Restroom facilities Excellent	Restroom facilities Good	Restroom facilities Fair	Restroom facilities Poor	Restroom facilities N/A
Bedroom comfort	Bedroom comfort Excellent	Bedroom comfort Good	Bedroom comfort Fair	Bedroom comfort Poor	Bedroom comfort N/A
Cleanliness	Cleanliness Excellent	Cleanliness Good	Cleanliness Fair	Cleanliness Poor	Cleanliness N/A
Temperature	Temperature Excellent	Temperature Good	Temperature Fair	Temperature Poor	Temperature N/A

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* 7. Please rate our office staff based on the following, if applicable:

	Excellent	Good	Fair	Poor	N/A
Knowledge of office staff	Knowledge of office staff Excellent	Knowledge of office staff Good	Knowledge of office staff Fair	Knowledge of office staff Poor	Knowledge of office staff N/A
Promptness to fulfill needs	Promptness to fulfill needs Excellent	Promptness to fulfill needs Good	Promptness to fulfill needs Fair	Promptness to fulfill needs Poor	Promptness to fulfill needs N/A
Willingness to assist you	Willingness to assist you Excellent	Willingness to assist you Good	Willingness to assist you Fair	Willingness to assist you Poor	Willingness to assist you N/A
Knowledge of technical staff	Knowledge of technical staff Excellent	Knowledge of technical staff Good	Knowledge of technical staff Fair	Knowledge of technical staff Poor	Knowledge of technical staff N/A

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* 8. Please rate our office procedures based on the following, if applicable:

	Excellent	Good	Fair	Poor	N/A
Scheduling procedures	Scheduling procedures Excellent	Scheduling procedures Good	Scheduling procedures Fair	Scheduling procedures Poor	Scheduling procedures N/A
Technical staff's set-up procedures	Technical staff's set-up procedures Excellent	Technical staff's set-up procedures Good	Technical staff's set-up procedures Fair	Technical staff's set-up procedures Poor	Technical staff's set-up procedures N/A
Clinical staff's CPAP demo/explanation	Clinical staff's CPAP demo/explanation Excellent	Clinical staff's CPAP demo/explanation Good	Clinical staff's CPAP demo/explanation Fair	Clinical staff's CPAP demo/explanation Poor	Clinical staff's CPAP demo/explanation N/A
Electrode removal/clean-up after PSG	Electrode removal/clean-up after PSG Excellent	Electrode removal/clean-up after PSG Good	Electrode removal/clean-up after PSG Fair	Electrode removal/clean-up after PSG Poor	Electrode removal/clean-up after PSG N/A
Overall how satisfied were you with the care received at our facility?	Overall how satisfied were you with the care received at our facility? Excellent	Overall how satisfied were you with the care received at our facility? Good	Overall how satisfied were you with the care received at our facility? Fair	Overall how satisfied were you with the care received at our facility? Poor	Overall how satisfied were you with the care received at our facility? N/A

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* 9. Please list any additional comments regarding staff, facility or procedures. We welcome suggstions for improvements.

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* 10. Please enter the information below (optional)

Name

Date of Visit