Physician Survey Form
Please complete the Physician Survey Form to share your professional profile and insights. All questions are required unless otherwise indicated.
Full Name
*
First Name
Last Name
Primary Medical Specialty
*
Please Select
Internal Medicine
Family Medicine
Pediatrics
Surgery
Psychiatry
Emergency Medicine
Obstetrics & Gynecology
Other
Years in Practice
*
Please Select
Less than 5 years
5-10 years
11-20 years
More than 20 years
Type of Practice
*
Solo Practice
Group Practice
Hospital-Based
Academic/Teaching
Other
Practice Location (City, State/Province)
*
How satisfied are you with your current work-life balance?
*
1
2
3
4
5
Which of the following are your biggest professional challenges? (Select all that apply)
*
Administrative burden
Patient volume
Keeping up with medical advances
Insurance/reimbursement issues
Work-life balance
Other
Please rate your agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I have access to the resources I need to provide quality care.
1
2
3
4
5
I feel supported by my organization.
6
7
8
9
10
I am satisfied with the professional development opportunities available to me.
11
12
13
14
15
What additional support or resources would help you in your practice?
Would you recommend your current practice setting to other physicians?
*
Yes
No
Not Sure
Submit
Should be Empty: