Name:   Email address:

1. Who was your treating physician?
  Dr. Ahmed Kutty Dr. Aamir Hameed

2. When did you visit us last?
  1 month ago   3-6 months ago   7-12 months ago

3. When you telephoned our office, did the receptionist answer your call courteously?
  Yes   No

4. Have you ever telephoned our office and received no response?
  Yes   No

5. Did you receive an appointment within a reasonable length of time?
  Yes   No

6. Upon arrival, did you find a convenient parking space?
  Yes   No

7. Did you have difficulty locating our office?
  Yes   No

8. Upon arrival, did the receptionist greet you courteously?
  Yes   No

9. Are the chairs and furnishings in our reception room satisfactory?
  Yes   No

10. Did you like the selection of magazines in our reception room?
    Yes     No

11. Were our assistants courteous, pleasant, helpful, and efficient in conducting you to an examining room?
    Yes     No

12. Upon arrival for your appointment, how long did you wait before beginning the history and/or examination?
    Less than 30 minutes     31 - 60 minutes     More than 60 minutes

13. Were you satisfied with the level of care and attention you received?
    Yes     No

14. How would you rate the doctor on his patience, warmth, and interest in your problem?
    Good     Hurried     Poor

15. How would you rate the doctor on professional thoroughness in the examination?
    Better than average     Average     Poor

16. After hours, have you ever had difficulty in reaching the doctor in an emergency?
    Yes     No

17. Did you understand the doctor's explanation of the results of your office visits?
    Yes     No

18. Did you have difficulty understanding our insurance form and statement?
    Yes     No

19. Comments:
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