Essential Family Chiropractic Office Survey

Do you feel the waiting room appears neat and clean? Yes No

Do you occasionally take pamphlets from the waiting room home for friends and family? Yes No

On a scale of 1-10 (10 being the best), how would you rate the following:

Office Lighting 1 2 3 4 5 6 7 8 9 10 Adjusting Room Layout 1 2 3 4 5 6 7 8 9 10 Adjusting Room Decor (Posters, Charts, Posters) 1 2 3 4 5 6 7 8 9 10 Adjusting Room Tables (comfort) 1 2 3 4 5 6 7 8 9 10 Office Scent 1 2 3 4 5 6 7 8 9 10 Office Carpeting 1 2 3 4 5 6 7 8 9 10

Of the above list, the one change you would make immediately would be:

Is the person at the front desk professional? Yes No

Do you get appointments when they are convenient for you? Always Usually Never

When you miss an appointment do you like to get a reminder call that day? Yes No

Does the person at the front desk make you feel welcome? Yes No

Do you feel confident in the doctor's abilities? Yes No

How would you describe the doctor's adjusting techniques? (choose all that apply)

Gentle Forceful Comfortable Uncomfortable Painful

Are you comfortable discussing personal health concerns with the doctor? Yes No

Do you feel the doctor actively listens to your concerns? Yes No

Do you feel that the doctor has done an adequate job of explaining your condition? Yes No

Do you feel comfortable referring your family and friends to your doctor of chiropractic? Yes No

What is the one thing you would recommend your doctor change to better serve you or your family?

Are you currently under active care? (includes regular maintenance) Yes No

If you are no longer under care is it due to:

• Cost of Continued Care
• Skepticism about chiropractor
• You didn't get the results you expected
• Other reasons (please explain)

Do you believe that maintenance care is important to prevent your condition from returning after the initial intensive phase of care? Yes No

When trying to refer others to our office, what do you believe to be their primary obstacle?

• People don't understand what chiropractors do
• Skepticism because of previous experience with other chiropractors
• Cost of care
• You don't feel comfortable explaining chiropractic to others

On a scale of 1-10 (10 being the best) how would you describe your overall experience at Essential Family Chiropractic? 1 2 3 4 5 6 7 8 9 10

Would you like to receive our new monthly E-Newsletter? Yes No If yes, please give your E-mail address: