Date:
A. How long did you wait to see a physician or nurse on this visit?
0-10 min. 11-15 min. 16-20 min. 21-30 min. 31-40 min. 41-50 min. 51-60 min.
B. What kind of Health Care Provider did you see today?
Doctor R.N. Nurse Practitioner
C. I was treated with respect and courtesy.
strongly agree agree neutral disagree strongly disagree Comments:
D. All my questions were answered to my satisfaction.
strongly agreeagreeneutraldisagreestrongly disagreeComments:
E. Did you clearly understand your diagnosis, treatment and follow-up plan?
F. I received appropriate care for my health concerns.
G. I would come to Health Services again if needed.
H. Health Services helped me to continue to pursue my academic goals.
I. Please describe below what you learned during your visit:
J. How could Health Services better serve your needs?
The following information is optional. You may not complete any or all of it, but by doing so, you allow us to respond to you concerning your attitudes and perceptions of Health Services.
Thank you for your time!
Name:
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