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Surveys
2016
April
S
Samuel U Rodgers : Patient Satisfaction
Samuel U Rodgers : Patient Satisfaction
0%
Exit Survey
How long have you used our services?
Less than 6 months
6 months to less than 1 year
1 year to less than 3 years
3 years to less than 5 years
5 years or more
Which of our services do you use? Select all that apply.
Adult and Senior Services
Behavioral Health
Child and Adolescent Health
Dental
Women's Health
How frequently do you visit our office?
Every day
Every week
Every 2 - 3 weeks
Every month
Every 2 - 3 months
Every 4 - 6 months
Once or twice a year
How would you rate your level of satisfaction with us?
Highly satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Highly dissatisfied
How much do you rate us on the following attributes?
Well Below Average
Below Average
Average
Above Average
Well Above Average
Customer service
Professionalism
Quality of services
Understanding customers' needs
Staff
Price
Comment:
How likely are you to continue visiting us?
Very likely
Somewhat likely
Neutral
Somewhat unlikely
Very unlikely
How likely is it that you would recommend our services to a friend or colleague?
Very likely
Somewhat likely
Neutral
Somewhat unlikely
Very unlikely
Do you have any suggestions for improving our services?
What is your gender?
Male
Female
Prefer not to answer
Which category describes your age?
Younger than 18
18 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 or older
Prefer not to answer
What best describes your employment status?
Employed full-time
Employed part-time
Self-employed
Not employed, but looking for work
Not employed, not looking for work
Retired
Student
Military
Homemaker
Prefer not to answer
Other
Which of the following categories best describes the industry you work in?
Automotive
Advertising
Consulting Services
Education
Entertainment
Financial Services
Government Services
Healthcare
Human Resources
Information Technology
Marketing/Sales
Non-Profit
Pharmaceuticals
Public Relations
Technical Services
Travel
Other
Which category best describes your annual income?
Under $15,000
$15,000 - $29,999
$30,000 - $44,999
$45,000 - $59,999
$60,000 - $74,999
$75,000 - $89,999
$90,000 or more
Prefer not to answer
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