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The Center For Advanced Imaging : Physicians and Medical Professionals

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Administration

	Martin Hellkamp President martin@caimri.com
	Paul Hellkamp COO paul@caimri.com
	Luci MacCormack Director of Physician Relations luci@caimri.com
	Center for Advanced Imaging 2923 Franklin Street, Roanoke VA 24014 T- 540-581-0882 F- 540-581-0881

Questionnaire for Referring Physicians

This questionnaire is designed to assess the quality of imaging services provided to you. We would appreciate your comments, both positive and negative, which might help us in our continuing efforts to assure the quality of Imaging services and patient care.

For the following questions, please indicate your degree of satisfaction by checking the appropriate number, with 1 indicating "not satisfied" and 5 indicating "very satisfied".

1. CAI Department Operations
A. Scheduling Availability	1 2 3 4 5
B. Staffing	1 2 3 4 5
C. Patient feedback	1 2 3 4 5
2. Customer Service
A. Recognition of problems/complaints	1 2 3 4 5
B. Ability to solve problems/complaints	1 2 3 4 5
C. Implementation to prevent reoccurring problems/Complaints	1 2 3 4 5
3. Technologists
A. Interaction with physicians and staff	1 2 3 4 5
B. Friendly/Courteous	1 2 3 4 5
C. Feedback from patients	1 2 3 4 5
4. Radiologists
A. Quality/accuracy of interpretation	1 2 3 4 5
B. Coverage	1 2 3 4 5
C. Availability for consultation	1 2 3 4 5
5. Reports
A. Availability/timeliness of reports	1 2 3 4 5
B. Ease of obtaining telephone/fax reports	1 2 3 4 5
C. Assistance in locating reports/films	1 2 3 4 5
6. Quality of Studies, Including Film Quality for MRI/MRA
A. Spine	1 2 3 4 5
B. Head	1 2 3 4 5
C. Extremity	1 2 3 4 5
D. Angiography	1 2 3 4 5
E. Abdomen	1 2 3 4 5
F. Chest	1 2 3 4 5
7. Quality of Studies, Including Film Quality for CT
A. Spine	1 2 3 4 5
B. Head	1 2 3 4 5
C. Extremity	1 2 3 4 5
D. CTA	1 2 3 4 5
E. Abdomen	1 2 3 4 5
F. Chest	1 2 3 4 5
8. Quality of Studies, Including Film Quality for Ultrasound
A. Abdomen (RUQ,Gall Bladder,Pancreas,Complete)
B. Aorta	1 2 3 4 5
C. OB	1 2 3 4 5
D. Pelvic	1 2 3 4 5
E. Renal	1 2 3 4 5
F. Testicular	1 2 3 4 5
G. Thyroid	1 2 3 4 5
H. Vascular (Arm,Carotid,Leg,Other)	1 2 3 4 5
9. Please specify services or procedures you would like to see added to CAI?
10. Please indicate your medical/surgical specialty:	Dental/Maxillo-facial Internal Medicine Pediatrics Emergency Neurology Podiatry ENT OB/GYN Psychiatry Family Practice Ophthalmology Urology Surgery Orthopedics Cardiology Pathology Physical Medicine/Rehab Other:
General Comments:
Name of Physician and Practice:
E-mail Address

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