1. When scheduling your appointment, how long did it take you to get in ?
Less than a week Greater than a week

2. When you entered our clinic, were you greeted by the receptionist ?
Yes No

3. How long was your wait time once you checked in with the receptionist ?
Less than 15 min Greater than 15 min More than 1 hr

4. Did you have any problems finding the clinic ?
Yes No

5. Did you have any problems getting into and out of the clinic office or parking lot ?
Yes No

6. How did you find out about Dr. Nelson? (check all that apply):
Newspaper: Primary Care Provider: Other Specialist Provider:
Internet Search: Referral From Friend: Other:

7. On a scale of 1-5 , how would you rate the courteousness of the office staff :

	1	2	3	4	5
• Courteousness of the Physician:
• Courteousness of the Nurse:
• Courteousness of the Technician:

8. Did you feel there was an overall teamwork and cooperation among the staff ?
Yes No

9. If you had a procedure, was the procedure explained to you prior to your testing ?
Yes No Not Applicable

10. Was the procedure explained to you in a manner you understood ?
Yes No Not Applicable

11. Did the physician explain your diagnosis/results ?
Yes No

12. Did you have to reschedule your initial appointment ?
Yes No

13. Did you receive a phone call reminding you of your appointment ?
Yes No

14. Overall, how would you rate your encounter at our Neurology Clinic ?
Not Satisfied Satisfied Very Satisfied

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