Health Care Survey
Sex: Male Female
Year: Freshman Sophmore Junior Senior
Who did you see: Doctor Nurse
Were you attended to within an appropriate time frame? Yes No
Comments:
Was satisfactory attention given to your personal needs? Yes No
Did you learn information today that will assist you with self care? Yes No
Did you learn information today that will help prevent this condition in the future? Yes No
Do you have any reservation about using the Health Center? Yes No
If yes, what are they and why?
Would you recommend the Health Center to other students? Yes No
Why or why not?
Do you have any suggestions to improve the health center?
On the scale listed below, please select your rating of the following:
Atmosphere of the office: PoorSatisfactoryGoodExcellentNo Rating Selected
Courtesy of the nurse: PoorSatisfactoryGoodExcellentNo Rating Selected
Courtesy of the doctor: PoorSatisfactoryGoodExcellentNo Rating Selected
Impression of confidentiality: PoorSatisfactoryGoodExcellentNo Rating Selected
Personal attention: PoorSatisfactoryGoodExcellentNo Rating Selected
Length of wait: PoorSatisfactoryGoodExcellentNo Rating Selected
Appointment scheduling: PoorSatisfactoryGoodExcellentNo Rating Selected
Education materials and programs: PoorSatisfactoryGoodExcellentNo Rating Selected
Would you like someone to contact you about your concerns? Yes No
If yes, please give us your name and number.
Name:
Telephone:
Email: