Month of Visit:

This is my first visit:

  Yes      No      None

I was referred to the practice by:

 Referring Physician     Friend     Self     Other     None

If Other, please specify:

I was referred for the following services:

 Sweet Success/Diabetes and Pregnancy     Diagnostic Testing     Consultation     Genetic Counseling     Other

If Other, please specify:

Ease of making my appointment:

 Excellent     Good     Fair     Poor     n/a     None

Appointment available within a reasonable amount of time:

 Excellent     Good     Fair     Poor     n/a     None

Ease of check-in and registration process:

 Excellent     Good     Fair     Poor     n/a     None

Waiting time in the reception area:

 Excellent     Good     Fair     Poor     n/a     None

Waiting time in the exam room:

 Excellent     Good     Fair     Poor     n/a     None

Ease of getting a referral:

 Excellent     Good     Fair     Poor     n/a     None

The courtesy and respect of the people I spoke with on the phone:

 Excellent     Good     Fair     Poor     n/a     None

The courtesy and respect of the nursing staff:

 Excellent     Good     Fair     Poor     n/a     None

The courtesy and respect of the care providers (physicians, nurses):

 Excellent     Good     Fair     Poor     n/a     None

The courtesy and respect of the sonographers:

 Excellent     Good     Fair     Poor     n/a     None

The courtesy and respect of the genetic counselor:

 Excellent     Good     Fair     Poor     n/a     None

The courtesy and respect of the certified diabetes educators:

 Excellent     Good     Fair     Poor     n/a     None

The helpfulness of the people in the business office:

 Excellent     Good     Fair     Poor     n/a     None

My phone calls were answered promptly:

 Always     Occasionally     Sometimes     Never     n/a     None

Availability of medical information/advice by telephone:

 Excellent     Good     Fair     Poor     n/a     None

Ability to obtain prescriptions by phone:

 Excellent     Good     Fair     Poor     n/a     None

Test results reported in a reasonable amount of time:

 Excellent     Good     Fair     Poor     n/a     None

Explanations concerning procedures and tests during my pregnancy:

 Excellent     Good     Fair     Poor     n/a     None

Ability to contact the office after hours:

 Excellent     Good     Fair     Poor     n/a     None

Care provider listened to my questions and concerns:

 Excellent     Good     Fair     Poor     n/a     None

Care provider answered my questions:

 Excellent     Good     Fair     Poor     n/a     None

Care provider’s instructions relate to my care or treatment:

 Excellent     Good     Fair     Poor     n/a     None

Hours of operation:

 Excellent     Good     Fair     Poor     n/a     None

Overall comfort of the office/facility:

 Excellent     Good     Fair     Poor     n/a     None

Availability of parking:

 Excellent     Good     Fair     Poor     n/a     None

Office/facility signs and directions are easy to follow.

 Excellent     Good     Fair     Poor     n/a     None

Overall satisfaction with the practice:

 Excellent     Good     Fair     Poor     n/a     None

Overall satisfaction with the quality of my medical care:

 Excellent     Good     Fair     Poor     n/a     None

I would recommend the practice to others.

  Yes      No      None

If no, please explain why.

My office visit included:

 ultrasound only     OB office visit     genetic counseling     ante partum testing

The provider who cared for me during my visit was:

My age group is:

 under 18     18-30     31-40     41-50     51-60     None

Please use the space provided below for any additional comments.