2 minutes
This form is to be completed by a patient who was under the observation of the physician.
What is your name?
Phone Number
Age
Name of Physician
How often is the physician available when you need him/her?
How often does the physician explain things clearly?
How often does the physician show concern for your welfare?
How often does the physician seem interested in your problems?
How often does the physician seem up-to-date in his/her knowledge?
How often does the physician provide you with referrals to specialists when necessary?
How often are you able to get an appointment with the physician when you need one?