Dear Upstate Cardiology Patient

We truly appreciate that you have chosen Upstate Cardiology for your healthcare needs.

We would welcome the opportunity to hear from you in regards to how we are doing so that we can best serve you. Thank you for taking the time to complete this survey. We need and value your feedback.

1) In the last 12 months, when you phoned Upstate Cardiology for care you needed right away, how often did you get an appointment as soon as you needed?□ Always□ Usually□ Sometimes□ Never

2) In the last 12 months, when you made an appointment for a check-up or routine care with us, how often did you get an appointment as soon as you needed? □ Always□ Usually□ Sometimes□ Never

3) In the last 12 months, when you contacted Upstate Cardiology during regular office hours, how often did you get an answer to your medical question that same day?

□ Always□ Usually□ Sometimes□ Never

4) In the last 12 months, when you contacted Upstate Cardiology after regular office hours, how often did you get an answer to your medical question as soon as you needed?

□ Always□ Usually□ Sometimes□ Never

5) In the last 12 months, how often did you see your provider at Upstate Cardiology within 15 minutes of your appointment time?

□ Always□ Usually□ Sometimes□ Never

6) How long has it been since your most recent visit with Upstate Cardiology?

□ Less than 1 month□ At least 1 month, but less

than 3 months□ At least 3 months, but less

than 6 months□ At least 6 months, but less

than 12 months□ 12 months or more

Your Care From Upstate Cardiology Within The Last 12 Months

7) During your most recent visit, did you see your provider at Upstate Cardiology within 15 minutes of your appointment time?

□ Yes□ No

8) During your most recent visit, did your provider explain things in a way that was easy to understand?

□ Yes, definitely□ Yes, somewhat□ No

9) During your most recent visit, did you talk with your provider about any health questions or concerns?

□ Yes□ No If “No”, skip to # 11

10) During your most recent visit, did your provider give you easy to understand information about your health questions or concerns?

□ Yes, definitely□ Yes, somewhat□ No

11) During your most recent visit, did your provider seem to know the important information about your medical history?

□ Yes, definitely□ Yes, somewhat□ No

12) During your most recent visit, did your provider listen carefully to you?

□ Yes, definitely□ Yes, somewhat□ No

13) During your most recent visit, did your provider show respect for what you had to say?

□ Yes, definitely□ Yes, somewhat□ No

14) During your most recent visit, did your provider spend enough time with you?

□ Yes, definitely□ Yes, somewhat□ No

15) During your most recent visit, did your provider order a nuclear study, echocardiogram, or other type of test for you?

□ Yes□ No If “No”, go to # 17

16) Did someone from Upstate Cardiology follow up to give you the results of that test?

□ Yes□ No

17) During your most recent visit, were the clerks and receptionists at Upstate Cardiology as helpful as you felt they should have been?

□ Yes, definitely□ Yes, somewhat□ No

18) During your most recent visit, did the clerks and receptionists treat you with courtesy and respect?

□ Yes, definitely□ Yes, somewhat□ No

Your Care From Upstate Cardiology During Your Most Recent Visit

19) Using any number from 1 to 10, where zero is the worst rating possible and ten is the best, what number would you use to rate your experience at Upstate Cardiology?

Please identify staff that went out of their way to help you, describe a good or bad experience, or notify us about anything else in the comments section below. Feel free to use the back of this form if you need more space. Thank you for choosing Upstate Cardiology.

Comments:

Contact Information (Optional):Name:

□ 1 6

□ 2 7

□ 3 8

□ 4 9

□ 5 10

20) Would you recommend us to your friends and family?

□ Yes□ No If “No”, please explain

why in the comments section below.

Telephone Number:

Email: