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. The provider listened carefully to my concerns. strongly agree agree neutral disagree strongly disagree Comments: D. I was treated with respect and courtesy. strongly agree agree neutral disagree strongly disagree Comments: E. All my questions were answered to my satisfaction. strongly agree agree neutral disagree strongly disagree Comments: F. Did you clearly understand your diagnosis, treatment and follow-up plan? strongly agree agree neutral disagree strongly disagree Comments: G. Overall, how satisfied are you with the services you received at Health Services? very satisfied satisfied neutral/don't know dissatisfied very dissatisfied Comments: H. I received information during my visit that I will use to improve my health. strongly agree agree neutral disagree strongly disagree Comments: 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: Phone:
