Health Care Survey

Sex:

Year:

Who did you see?

What was the reason for your visit?

The number of times I have visited the Health Center this academic year:

Patient education is important to us.

Did the practitioner provide clear instructions and information regarding your condition?

Were you given information at your visit that helped you to be responsible for your health?

Why or why not?

Do you have any reservation about using the Health Center?

If yes, what are they and why?

Would you recommend the Health Center to other students?

Why or why not?

Do you have any suggestions to improve the Health Center?

Do you think that Health Services supported your class attendance and involvement in campus activities?

On the scale listed below, please select your rating of the following:

Atmosphere of the office:

Courtesy of the nurse:

Courtesy of the doctor or physician's assistant:

Impression of confidentiality:

Personal attention:

Length of wait:

Appointment availability:

Education materials:

Would you like someone to contact you about your concerns?

If yes, please give us your name and number.

Name:

Telephone:

Email: