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Patient Survey
Patient Survey
Did your referring physician explain the exam to you?
Yes
No
While you were in the department, was the examination explained to your satisfaction?
Yes
No
If there was a delay in starting your exam, was the reason explained to you adequately prior to your exam?
Yes
No
Please rate the ease and timeliness of appointment scheduling?
Excellent
Good
Unsatisfactory
N/A
Which word best describes the service you received from the Diagnostic Imaging staff?
Receptionist/Scheduling
Excellent
Good
Unsatisfactory
N/A
Nurse who started IV
Excellent
Good
Unsatisfactory
N/A
Nuclear Medicine Technologist
Excellent
Good
Unsatisfactory
N/A
Treadmill/Exercise Nurse
Excellent
Good
Unsatisfactory
N/A
Treadmill/Exercise Physician
Excellent
Good
Unsatisfactory
N/A
Which term best describes the cleanliness of the Nuclear Medicine Unit?
Excellent
Good
Unsatisfactory
If you were not taken for your exam at your appointment time, how long was your wait?
0-15 minutes
16-30 minutes
Over 30 minutes
How long?
Additional Comments?
Demographics
Date of Exam:
Name: (OPTIONAL)