Annual Physician Survey Dallas / Plano We would appreciate you responding to the following questions concerning the home health services we have provided you and your patients. Your comments will assist us in providing the best possible services to you in the future. If you have any questions or concerns at any time, please feel free to contact the agency at 972-203-8200.
Name of the person filling out the survey:
FIRST NAME:
LAST NAME:
TITLE:
If you are NOT the physician, please tell us your physician's name here!	First Name Last Name Practice Name
PLEASE RATE THE FOLLOWING SERVICES:	Please Choose One 1 = Poor / 2 = Fair 3 = Good / 4 = Excellent
Nursing	1234
Physical Therapy	1234
Occupational Therapy	1234
Speech Language Pathology	1234
Medical Social Worker	1234
Home Health Aides	1234
Communication with our staff	1234
Changes in patients' conditions are reported timely and completely	1234
Satisfaction with Plans of Care and how they are carried out	1234
Patient summaries effectively communicate their health status	1234
Would you refer other patients to our agency?	YESNO
Would you like to receive a follow up call?	YESNO
Comments