Medical Examination Services Survey Template

Medical Service Evaluation survey for desirability of medical examination features, and customer attitudes of current services.



   
The following set of questions deals with medical examination services. These services are performed during routine examinations. Please rate the level of importance for each service.
Not At All Important Somewhat Unimportant Neutral Somewhat Important Very Important Not applicable/
Not sure
Speed in completing examinations
Accuracy and completeness in filling out your report
Expertise of medical staff
Medical representative treatment
Offers all services required for examination
Wide geographic area of service coverage
Hand delivery of reports to insurance office
Personal relationship
 
   
 
 
   
 
   
 
If a medical examination service were to guarantee:

(A)    Professionalism in the medical staff

(B)    Accurately filled out and completed reports

(C)    A completed report back to you within 3 days


Would you change to this agency?
 
No
 
Yes
 
Not sure
 
   
 
 
   
 
   
How would you rate on each of the following items with your current medical service provider?
Excellent Very Good Good Fair Poor Not applicable/
Not sure
Speed in completing examination and reports
Accuracy and completeness in filling out your report
Expertise of medical staff
Medical representative treatment
Offers all services required for examination
Wide geographic area of service coverage
Hand delivery of reports to insurance office
Personal relationship with your medical representative
 
   
 
 
   
 
   
 
 
   
 

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