Doctor Performance Patient Evaluation Form
Please provide your feedback about your recent experience with your doctor. Your input helps us improve our services.
Patient Full Name
*
First Name
Last Name
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Doctor's Name
*
Department / Specialty
*
Please Select
Internal Medicine
Pediatrics
Surgery
Cardiology
Dermatology
Orthopedics
Other
How would you rate the doctor's communication skills?
*
1
2
3
4
5
How would you rate the doctor's professionalism?
*
1
2
3
4
5
How well did the doctor explain your condition and treatment options?
*
Not at all clear
1
2
3
4
Extremely clear
5
1 is Not at all clear, 5 is Extremely clear
Please indicate your level of agreement with the following statements about your doctor:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The doctor listened carefully to my concerns.
1
2
3
4
5
The doctor answered my questions thoroughly.
6
7
8
9
10
The doctor was respectful and courteous.
11
12
13
14
15
The doctor involved me in decisions about my care.
16
17
18
19
20
Overall, how satisfied are you with the care you received from this doctor?
*
Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
What did you appreciate most about your visit with this doctor?
Do you have any suggestions for how the doctor could improve?
Submit Evaluation
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