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Patient's Survey

What is your gender?

Female

Male
What is your age group?

Less than 20 years old

Between 21 and 30

Between 31 and 40

Between 41 and 50

Over 50
Reason for today's visit

Physicals

Respiratory Infection

Stomach Pain

Diabetes Hypertension
Other (please specify)
Your last visit to the clinic was at
Anaheim Market Clinic - Anaheim
Costa Mesa Medical Clinic - Costa Mesa
Ruiz Patel Medical Inc. - Santa Ana
Ruiz Patel Medical Clinic - Corona
El Toro Medical Clinic - Lake Forest
Riverside Market Clinic - Riverside
Indio Medical Clinic - Indio
The staff was friendly and courteous
* Please answer each question
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
The treatment rooms were neat and clean
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
Comments (please specify)
The physician spent the time needed to evaluate my health needs
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
The physician understood & listen carefully to my health problems and concerns
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
I was satisfied with the visit
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
My questions were answered
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
Comments (please specify)
The physician was knowledgeable
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
I was explained about the treatment/condition
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
I was advised about general guide line to stay healthy
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
The cost of the care was reasonable
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
Overall, I was extremely satisfied with the service I was provided with
The service was prompt
The staff was courteous and efficient
I would most likely refer others to the clinics
Very likely
Likely
Unlikely
Overall, I was extremely satisfied with my visit
Strongly Disagree
Disagree
Fair
Agree
Strongly Agree
Comments (please specify)
Enter the code as it is shown:*
 
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