Internal Medicine Associates of John's Creek, Inc. - Samantha B. Benson, MD

Thank you for choosing Internal Medicine Associates as your primary care provider. Our goal is to work with you to provide the best possible care and process we can. We have developed an online survey to help us identify our strengths and weaknesses. We are asking for your assistance to help improve as well as to identify an employee who you feel really helped you to have a great experience.

1)	What was the purpose of your visit to our office?


2)	Did you have an appointment?
	Yes No

3)	How long did you have to wait before you were seen by a provider?


Please tell us how satisfied or dissatisfied you were with each of the following:
4)	How satisfied were you with the way you were treated by the staff at our office?
	Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied

5)	How satisfied were you with the way you were treated by the nurse?
	Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied

6)	How satisfied were you with the way you were treated by the provider?
	Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied

7)	The amount of time the provider spent with you?
	Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied

8)	The amount of time you had to wait before being seen by a provider?
	Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied

9)	How satisfied were you with the way your questions were answered?
	Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied

10)	How would you rate the courtesy you were shown by staff at our office?
	Excellent Good Fair Poor Don't Know

Please tell us how much you agree or disagree with the following statements:
11)	The nurse was friendly and courteous.
	Strongly Disagree Disagree Undecided Agree Strongly Agree

12)	The provider was knowledgeable.
	Strongly Disagree Disagree Undecided Agree Strongly Agree

13)	The provider was friendly and courteous.
	Strongly Disagree Disagree Undecided Agree Strongly Agree

14)	I was given complete attention by the provider.
	Strongly Disagree Disagree Undecided Agree Strongly Agree

15)	Overall, How would you say your visit to our office was?
	Very Positive Somewhat Positive Undecided Somewhat Negative Very Negative

16)	What, if anything, did you like most about your visit to our office?


17)	What, if anything, did you like least about your visit to our office?


18)	Please tell us what, if anything, we can do to make future visits to our office more pleasant for you.


19)	Which employee helped you the most and provided you with the best service during your visit?