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1. Dear Upstate Cardiology Patient
We truly appreciate that you havechosen Upstate Cardiology for your healthcare
needs.
We would welcome the opportunity to hear fromyou in regards to how we are
doing so that we can best serveyou. Thank you for taking the time to complete
this survey. Weneed and value your feedback.
1) In the last 12 months, when you
phoned Upstate Cardiology for care
you needed right away, how often
did you get an appointment as soon
as you needed?
□ Always
□ Usually
□ Sometimes
□ Never
2) In the last 12 months, when you
made an appointment for a check-
up or routine care with us, how
often did you get an appointment as
soon as you needed?
□ Always
□ Usually
□ Sometimes
□ Never
3) In the last 12 months, when you
contacted Upstate Cardiology during
regular office hours, how often did
you get an answer to your medical
question that same day?
□ Always
□ Usually
□ Sometimes
□ Never
4) In the last 12 months, when you
contacted Upstate Cardiology after
regular office hours, how often did
you get an answer to your medical
question as soon as you needed?
□ Always
□ Usually
□ Sometimes
□ Never
5) In the last 12 months, how often did
you see your provider at Upstate
Cardiology within 15 minutes of
your appointment time?
□ Always
□ Usually
□ Sometimes
□ Never
6) In the last 12 months, how many
times did you visit Upstate
Cardiology for your healthcare
needs?
□ First visit
□ One time
□ Two times
□ Three times
□ Four times
□ Five or more times
Your Care From Upstate Cardiology WithinThe Last 12 Months

2. 7) During your most recent visit, did
you see your provider at Upstate
Cardiology within 15 minutes of
your appointment time?
□ Yes
□ No
8) During your most recent visit, did
your provider explain things in a way
that was easy to understand?
□ Yes, definitely
□ Yes, somewhat
□ No
9) During your most recent visit, did
your provider seem to know the
important information about your
medical history?
□ Yes, definitely
□ Yes, somewhat
□ No
10) During your most recent visit, did
your provider listen carefully to you?
□ Yes, definitely
□ Yes, somewhat
□ No
11) During your most recent visit, did
your provider show respect for what
you had to say?
□ Yes, definitely
□ Yes, somewhat
□ No
12) During your most recent visit, did
your provider spend enough time
with you?
□ Yes, definitely
□ Yes, somewhat
□ No
13) During your most recent visit, did
your provider order a nuclear study,
echocardiogram, or other type of
test for you?
□ Yes
□ No  If “No”, go to # 15
14) Did someone from Upstate
Cardiology give you information on
how you will receive follow up
information from those tests?
□ Yes
□ No
15) During your most recent visit, were
the clerks and receptionists at
Upstate Cardiology as helpful as you
felt they should have been?
□ Yes, definitely
□ Yes, somewhat
□ No
16) During your most recent visit, did
the clerks and receptionists treat
you with courtesy and respect?
□ Yes, definitely
□ Yes, somewhat
□ No
17) Using any number from 1 to 10,
where zero is the worst rating
possible and ten is the best, what
number would you use to rate your
experience at Upstate Cardiology?
Your Care From Upstate Cardiology During Your Most Recent Visit
□ 1 6
□ 2 7
□ 3 8
□ 4 9
□ 5 10
18) Would you recommend us to your
friends and family?
□ Yes
□ No If “No”, please explain
why in the comments section
below.

3. Please identify staff that went out of their way to help you, describea good or
bad experience, or notify us about anything else in the comments section below.
Thank you for choosing Upstate Cardiology.
Comments:
Contact Information(Optional):
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