Pediatric Patient Satisfaction Survey Welcome to your 2023 Pediatric Patient Satisfaction Survey. Please answer the questions below based on a recent visit your child had at his/her Pediatric or primary care practice. Please indicate the name of your practice, provider seen, and the name of your health insurance. Select the best answer that describes you/your child’s experience and satisfaction. During this visit, your child’s care was provided by a Doctor (MD/DO), Nurse Practitioner (NP) or Physician Assistant (PA). Please answer the following questions based on the experience received with that health care provider in mind. Primary Care Practice Primary Care Provider Seen Name of Health Insurance Date Primary Care Practice Primary Care Provider seen Name of Health Insurance Date 1. Friendliness/courtesy of the front desk staff: Very Poor Poor Fair Good Very Good None 2. Ease of getting an appointment when your child needed it Very Poor Poor Fair Good Very Good None 3. Friendliness/courtesy of nurse or medical assistant: Very Poor Poor Fair Good Very Good None 4. Friendliness/courtesy of the care provider: Very Poor Poor Fair Good Very Good None 5. Explanations the care provider gave you/your child about his/her condition: Very Poor Poor Fair Good Very Good None 6. Concern the care provider showed for you/your child’s concerns: Very Poor Poor Fair Good Very Good None 7. Care provider’s efforts to include you/your child in decisions about treatment: Very Poor Poor Fair Good Very Good None 8. Degree to which care provider talked using words you/your child could understand: Very Poor Poor Fair Good Very Good None 9. Amount of time the care provider spent with you/your child: Very Poor Poor Fair Good Very Good None 10. Amount of time you/your child waited in the office to see the care provider: Very Poor Poor Fair Good Very Good None 11. The confidence that you have in this care provider: Very Poor Poor Fair Good Very Good None 12. Likelihood of recommending this care provider to others: Very Poor Poor Fair Good Very Good None 13. Likelihood of recommending this practice to others: Very Poor Poor Fair Good Very Good None Comments (describe good or bad experience) Time's up
