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MrsMD Weight Loss Patient Survey

Measha Dancy, MD

Dorinda Ezell, FNP

Omotola Omolayo, PA-C

David Purselle, MD

Linda Yatak, PMH-NP

Survey

Which provider did you see?

What was your primary goal for seeking weight loss services? (Check all that apply)

Lose a specific amount of weight

Improve a specific health measure (e.g., blood pressure, cholesterol)

Increase energy levels

Improve body image/confidence

Other (please specify)

Please specify your goal (Optional)

Overall, how satisfied were you with your experience at MrsMD?

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

Overall Satisfaction Comment (Optional)

How would you rate the ease of scheduling your appointment?

Very Easy

Easy

Neutral

Difficult

Very Difficult

Scheduling Comment (Optional)

How would you rate the friendliness and helpfulness of our front desk staff?

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

Front Desk Staff Comment (Optional)

How would you rate the clinician's communication skills?

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

Clinician's Communication Comment (Optional)

Did the clinician explain your weight loss plan and options clearly?

Very Clearly

Somewhat Clearly

Neutral

Somewhat Unclearly

Very Unclearly

Clinician's Explanation Comment (Optional)

How satisfied were you with the level of support and encouragement you received from the clinician?

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

Clinician's Support Comment (Optional)

How satisfied were you with the diet plan recommendations?

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

Diet Plan Comment (Optional)

How satisfied were you with the exercise recommendations?

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

Exercise Plan Comment (Optional)

How satisfied were you with the medication recommendations?

Very Satisfied

Satisfied

Neutral

Dissatisfied

Very Dissatisfied

Medication Plan Comment (Optional)

How likely are you to recommend our clinic to a friend or family member?

Very Likely

Likely

Neither Likely nor Unlikely

Unlikely

Very Unlikely

What specific aspect of our services could be improved?

Is there anything else you would like to share about your experience?

Would you like someone from the clinic to contact you regarding this survey?

Yes

No

First Name

Last Name

Email

Phone/Mobile

Average

Overall

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