Nevadapain.com / Pain Specialist, Neck Pain, Back Pain, Pain Treatment

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PATIENT SATISFACTION SURVEY

Dear Patient,

We ask you take a minute and fill out this survey; the information will help to better serve you.

This information is completely anonymous.

Age:		20-30		31-40		41-50
		51-60		61-70		Above 70

Sex:

Male

Female

Was there a long waiting time (waiting area) before you were seen?	Yes	No
If yes, what is an acceptable wait time to you?	0-15 min	15-30 min
	30-45 min	45-60 min
Was there a long time before you were seen for your initial evaluation?	Yes	No
If yes, what is an acceptable wait time to you?	1-2 Weeks	2-4 Weeks
	4-6 Weeks	6-8 Weeks
Do you think there was a long time between Follow up visits?	Yes	No
If yes, how often do you think you should be seen?	4 Weeks	6 Weeks
	8 Weeks	12 Weeks
Do you think it is easy to get in touch with the clinic by phone?	Yes	No
Are your calls being answered within 24-48 hours?	Yes	No

What was your pain level before you were seen in the pain clinic?		/10
What is your pain level now?		/10
What is an acceptable pain level to you?		/10
What was your pain level before you were seen in the pain clinic?		/10

How did the treatment impact your quality of life?	Better	Same
	Worse
Did any of the procedures help to reduce your pain?	Yes	No
If yes, by how much?	100%	75%
	50%	25% or less
Are you satisfied with your current level of pain control?	Yes	No
Do you think all your questions were addressed appropriately?	Yes	No
Would you recommend this clinic to others?	Yes	No
Do you feel that your privacy was respected?	Yes	No
Was our staff courteous to you and your needs?	Yes	No

What do you think we should do to improve our care?

Dr. Pouya Mohajer is Board Certified in Anesthesiology with a subspecialty certification in Pain Medicine by the American Board of Anesthesiology.