Interoffice Communication Design Questionnaire

             Name: 
          Address: 
                   
 City, State, Zip:  ,  , 
          Country: 

Person to contact: 
            Phone:   Email: 
        Specialty: 


    Facility Factors:             Staff: 

    No. of Each

                NOW        FUTURE               TOTAL#   #WORKING PER SHIFT


     Exam Rooms                   Doctors         


          Laser                    Nurses         


      Specialty                Assistants         


    Minor Proc.               Technicians         


    Dr's Office                      P.A.         


 Nurse Stations                  Business         


      Reception              Receptionist         


 Other (please specify below)    Other (please specify below)

                         

 Administrator: 


    Architecture:
  Type Building:   Existing      Remodel    New Construction 
   Type Ceiling:       Drop   Sheet Rock         Crawl Space 
                   Plenum Air Return    Duct Return 

        Architect: 
    Space Planner: 
          Builder: 


    Inter-office Traffic:
     1. Approximately how many patients do you see in a day?  

     2. How do patients get from the waiting room to the clinical area?
         Receptionist finds assistant and informs of patient arrival.
         Assistant routinely checks reception for charts.
         Other(please explain below).
           

      3. How do you know which patient is next to see?
         I ask someone.
         Someone tells me.
         Other(please explain below).
           

       4. How do you call for assistance from an exam room?
         I ask someone.
         Someone tells me.
         Use phone.
         Other(please explain below).
           

       5. Do you need to see any patients for a second time after a 
        special procedure is performed?
          Yes  No


    Telephone Communication:
     1. How many phone calls do you take during the work day? 

     2. What type of phone calls do you take during the work day?
         Consult
         Spouse
         Patient
         Emergency
         Other(please explain below).
           

     3. How are you informed of an important phone call?
         Receptionist finds me and informs me.
         Receptionist uses intercom.
         Message paged throughout office.
         Emergency
         Other(please explain below).
           


     Future Expansion:
      1. How many staff members do you contemplate adding in the next 
         two years? 


         Drs     Asts     Bus     Other     Not Adding 

      2. Will you be adding any rooms to your facility in the next 
         five years? 


         Exams     Offices     Other     Not Adding