Currently Compiling Data on
Long Island Region Physicians
Queens, Nassau, and Suffolk Counties ONLY

They are taking advantage of us.
Now's your chance to help make the system better!
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EVALUATE YOUR PHYSICIAN QUESTIONNAIRE

The medical situation seems to be getting worse and worse. Have you ever tried to make an emergency appointment with a doctor and find they cannot see you for two months? I'm talking about a doctor you have been seeing for many years (not as a new patient). Have you arrived for an appointment at your doctor's office and have had to wait in the waiting for an hour or more, only then to be ushered into an examining room and wait there for another half hour? What about sitting in a waiting room where the magazines are all about skiing (you have no interest in skiing) and problems of the senior citizen (and you're in your 20-60 with no interest in reading about senior problems) and these are old, torn and worn. I'm sure, like me, you plan your day around your appointment with your doctor. You drive like a lunatic to be sure you get to the office on time and then you arrive and sit and wait, and wait, and wait. When you finally get up a "head-of-steam" and complain to the nursing staff they look at you with total disdain and either say, the doctor had an emergency or the doctor doesn't like to rush his/her patients. It's finally your turn to sit with the doctor and get all your questions answered. But no, he's/she's in and out of the office before you can even think of why you're there. Each appointment is similar. You're left "cooling your heels" and the answer to your question to the nursing staff is still the same; the doctor had an emergency. OK, you can allow for an occasional emergency but when it's the excuse, visit after visit, you know there is little consideration for the patient.

This is what's happening all over. We, the people, are being taken advantage of. The medical world has decided that their time is valuable, ours is not. So let's not take it anymore. Fill out the Physician Evaluation below. By submitting the questionnaire you are agreeing that the information can be used in compiling a data base of information. We will use the information submitted by you about the doctor to compile a report and let the medical community know we're on to them. Your name and address will not be disclosed. However, your completed questionnaire cannot be accepted unless you submit your name, address and telephone number with the form. The plan is to compile the information by state. We are starting with Long Island, New York, and will expand from there. The information will be available to the public for a nominal fee to cover printing and other costs. Hope you will help by submitting the questionnaire below.

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Evaluate Your Physicians

Use One Form For Each Physician.

If you are submitting the questionnaire online from the website submit one questionnaire for each physician.
If you have this form as a hardcopy, you can make copies of this form so that each physician evaluation is submitted on a separate form.
or print forms from the website: www.eplace4u.com

Then go to: "Long Island's Best" to find the form.

If you have any questions or comments email me at: eplace4u@aol.com

Information About You

Your name and address will not be disclosed.

First Name (Required)

Last Name (Required)

Address (Required)

City (Required)

State (Required)

Zip (Required)

Area Code (Required)

Telephone No (Required)

YOUR Email (Required)

Information About Your Physician Below

Dr First Name (Required)

Dr Last Name (Required)

Dr Address (Required)

Dr City (Required)

State only accepting NY at this time

NY

Dr Zip (Required)

Area Code (Required)

Telephone No (Required)

Specialty

EVALUATE YOUR DOCTOR
YES
NO

1. Keeps you waiting more than 1/2 hour after you arrive on time for scheduled appointment.

2. Keeps you waiting more than 1 hour after you arrive on time for scheduled appointment.

3. Keeps you waiting in examining room more than 20 minutes after you arrive on time for scheduled appointment.

4. Keeps you waiting more than 40 minutes in examining room after you arrive on time for scheduled appointment.

5. Doctor has good "bed-side" manner.

6. Doctor is brusque, rushed and you feel as though he/she is not interested in your health problems or questions.

7. Doctor is interested and concerned with your health problems or questions.

8. Doctor's office and examining room generally clean.

9. Staff generally is polite and kind.

10. Staff generally is rude and/or brusk.

11. Waiting room is comfortable.

12. Magazines for patients to peruse are recent, within 3-4 months and/or various themes, like for teens, housewives, working people and sports.

13. Magazines for patients to peruse are old more than 1-2 months old and/or subject matter of magazines very limited. For instance; mostly skiing or mostly boating.

OVERALL NUMERICAL RATING
RATE YOUR DOCTOR BELOW
Think of your overall comfort while waiting and while being examined
Rate Your Doctor On a scale of 1-10
1 being UNACCEPTABLE - - - 10 being the HIGHEST (THE BEST)

I rate my doctor, his/her office staff, general cleanliness and my comfort level:

Your notes and comments on this physician:

Privacy Statement
Your name and address will not be disclosed.

The Information We Collect
User Registration. Registration is strictly voluntary. To have your evaluation accepted you must provide your name, address, and e-mail address. This information is required in the registration process but we recognize that this is your personal information and we do not give it out to third parties. Registering by filling out physician evaluation form allows your evaluation to be included in our report. Your identification is not disclosed.

How We Use Your Information
We may use your e-mail address and home address to periodically send you updates. You may choose to not receive these communications by so indicating during the registration process or in response to one of our e-mails or postal mailings.

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First Name (Required)
Last Name (Required)
Address (Required)
City (Required)
State (Required)
Zip (Required)
Area Code (Required)
Telephone No (Required)
YOUR Email (Required)

Dr First Name (Required)
Dr Last Name (Required)
Dr Address (Required)
Dr City (Required)
State only accepting NY at this time	NY
Dr Zip (Required)
Area Code (Required)
Telephone No (Required)
Specialty

EVALUATE YOUR DOCTOR	YES	NO
1. Keeps you waiting more than 1/2 hour after you arrive on time for scheduled appointment.
2. Keeps you waiting more than 1 hour after you arrive on time for scheduled appointment.
3. Keeps you waiting in examining room more than 20 minutes after you arrive on time for scheduled appointment.
4. Keeps you waiting more than 40 minutes in examining room after you arrive on time for scheduled appointment.
5. Doctor has good "bed-side" manner.
6. Doctor is brusque, rushed and you feel as though he/she is not interested in your health problems or questions.
7. Doctor is interested and concerned with your health problems or questions.
8. Doctor's office and examining room generally clean.
9. Staff generally is polite and kind.
10. Staff generally is rude and/or brusk.
11. Waiting room is comfortable.
12. Magazines for patients to peruse are recent, within 3-4 months and/or various themes, like for teens, housewives, working people and sports.
13. Magazines for patients to peruse are old more than 1-2 months old and/or subject matter of magazines very limited. For instance; mostly skiing or mostly boating.

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