Sample Survey

The Personal Input Survey

A personal input survey is a questionnaire designed to obtain feedback from patients using a computer.  Table 3 shows an example of what can be posted on a practitioners web site or office intranet.  While the form below is a fully functioning form, it is not within the scope of this article to provide instructions on how to reconfigure this form to work within your system and/or Internet Service Provider's (ISP) requirements.  This form is provided as an example of what can be done to enhance communications with your patients electronically.   

Table 3.  A Sample Survey Form (Interactive)

Patient Satisfaction Survey

In order to provide you with the best dental services possible, we want to know how well we are doing now and what we might do better from your point of view.  Please take a couple of minutes to provide us with important information to assist us in our effort to better serve you.

Grade us by selecting either A, B, C, D or E after each question.

A= Excellent, B= Very Favorable, C= Favorable, D= Adequate, E= Inadequate

If you would like to add some constructive suggestions or comments, please feel free to do so in the space provided at the end of this questionnaire.

 
How easy was it to make an initial appointment?

 

 A B C D E
Were the forms you filled out easy to understand? A B C D E
Was the parking convenient? A B C D E
Was the reception area welcoming? A B C D E
Was the receptionist pleasant and helpful? A B C D E
Did you find the treatment area non-threatening? A B C D E
Did the dental care providers (dentist, hygienist, assistants)
treat you as you wanted to be treated during your visit?		 A B C D E
Does the business operation of the dental office manage
your account appropriately?		 A B C D E
Would you recommend this practice to your family and friends? A B C D E


Comments:

Thanks for your time!

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