Welcome back to my office. Please take a moment to record for me, in your own words, how you have done since the last visit. If your hand problem makes it difficult for you to fill this out, please ask my secretary to help you. My staff and I are here to serve you. Please let me know how we can serve you better.

Today's Date __________

What was the main problem that you came in for last time? ____________________________________________________________________________________________

Has your main problem from last time gotten better, worse, or stayed the same? Please explain. Here is your chance to be as specific as you want. You can use the back side if you need to. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________________________________________________________________

Is this still the main problem, or do you want to discuss something additional? _____________________________________________________________________________________________

Now tell me a little about us. Did the front desk staff help to make you feel comfortable? Were they helpful? _____________________________________________________________________________________________ _____________________________________________________________________________________________

Now tell me a bit about me, Dr. Nelson. Was I courteous? Did I give you enough time to ask questions? Did I explain your diagnosis to you in words you could understand? _____________________________________________________________________________________________ _____________________________________________________________________________________________

What could I do to be a better doctor for you? _____________________________________________________________________________________________ _____________________________________________________________________________________________

Have you looked at our website, www.DavidLNelson.MD? Was it helpful? What would you want to see added? _____________________________________________________________________________________________

Thank you for taking the time to let us know how you are doing and how we are doing. It is our goal to serve you. Please let us know if we are not achieving our goal. David Lincoln Nelson, MD