Survey Form

Required Optional Completed

Choose Location

Pediatric Medical Center
836 Paul St
Orlando, Florida, 32808
(407) 295-2039

Choose Physician

Personal Details

Your Name

Your Email

Your Phone Number

Relationship to Patient

Question 1 out of 33

Patients age:

Question 2 out of 33

Patient Gender:

Male

Female

Question 3 out of 33

Patients Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

Refused

Question 4 out of 33

What kind of Insurance do you have?

Commercial

Medicaid/Medicare

Selfpay

Refused

Question 5 out of 33

Were you able to reach our staff when you called us?

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 6 out of 33

The time between your call to schedule an appointment and the day of your appointment.

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 7 out of 33

Our Same day appointment/Office hours meet your needs?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 8 out of 33

The helpfulness and professionalism of our staff over the phone?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 9 out of 33

Did you need a Saturday Appointment? Were you able to get it?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 10 out of 33

The comfort, cleanliness and amenities of the reception area.

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 11 out of 33

Did you need a Same day Saturday Appointment? Were you able to get it?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 12 out of 33

Friendliness and courtesy of care providers.

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 13 out of 33

Amount of time the care provider spent with you.

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 14 out of 33

Explanations the care provider gave you about your problems or concerns.

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 15 out of 33

Did your physician and her team answer all of your questions?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 16 out of 33

Information the care provider gave you about the medication (if any)

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 17 out of 33

Your confidence in your Care Team.

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 18 out of 33

How likely would you recommend this care provider to others?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 19 out of 33

Your overall visit in the office.

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 20 out of 33

Did the physician and her team listen to your question/comments without interrupting?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 21 out of 33

Did you get the answer of your concerns/questions when you called the office after hours?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 22 out of 33

Was it helpful to you that your concerns/questions were addressed after hours?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 23 out of 33

How many times has the patient ended up in the E.R or urgent care center?

0

1-5

5+

Question 24 out of 33

Did Pediatric Medical Center call you to remind you about your appointment next day?

Not Applicable

No

Yes

Question 25 out of 33

Did Pediatric Medical Center call you to inform you about your recent lab results?

Not Applicable

No

Yes

Question 26 out of 33

Did Pediatric Medical Center call you to schedule an appointment about your recent lab results?

Not Applicable

No

Yes

Question 27 out of 33

Did the specialist that we referred to you addresses your concerns?

Not Applicable

No

Yes

Question 28 out of 33

Do you have access to patient portal (where you can view/download your health record?

Not Applicable

No

Yes

Question 29 out of 33

Are you and your children eating healthy?

Not Applicable

No

Yes

Question 30 out of 33

Were you able to get access to Pediatric Medical Center via Telemedicine?

Not Applicable

No

Yes

Question 31 out of 33

How did you schedule your appointment?

Office

Phone

Online

Walkin

Question 32 out of 33

Were you able to get in contact with Pediatric Medical Center after normal business hours?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

Question 33 out of 33

Your overall visit in the office?

Not Applicable

Completely Unsatisfied

Somewhat Unsatisfied

Satisfied

Somewhat Satisfied

Completely Satisfied

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