Northwest Indiana Occupational Medicine Specialists : Comprehensive Care

Patient Survey

Patient Information

Patient Age

Patient Gender

Male

Female

Position with Company

Please rate Comprehensive Care on the following

5 = Excellent 1 = Poor

Attended to in a timely manner:

Courtesy / Attitude of Employees:

Patient Care:

Clinic Appearance / Cleanliness:

Relationship with Medical Staff:

Relationship with Doctors / Therapists:

Rate Comp. Care vs. other health care experiences:

Overall Experience:

General Health Care Questions:

5 = High Priority 1 = No Concern

Importance of a solid company Health Plan:

Rating of your companies Health Plan:

Comfort with the Internet for health questions:

Would you be interested in any of the following programs for your employees: (Check all that apply)

If other is selected, please specify: