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> Health Services Satisfaction Survey
Satisfaction Survey
To help us improve our services, please complete this anonymous form.
All fields are required unless indicated otherwise.
Required:
It was easy to be seen by the nurse.
(select)
Not applicable
Very dissatisified
Somewhat dissatisified
Satisfied
Very Satisfied
The nurse was professional and courteous.
(select)
Not applicable
Very dissatisified
Somewhat dissatisified
Satisfied
Very Satisfied
The nurse was sensitive to privacy and confidentiality.
(select)
Not applicable
Very dissatisified
Somewhat dissatisified
Satisfied
Very Satisfied
I was advised of what to do if I didn’t feel better.
(select)
Not applicable
Very dissatisified
Somewhat dissatisified
Satisfied
Very Satisfied
Information given to me was helpful.
(select)
Not applicable
Very dissatisified
Somewhat dissatisified
Satisfied
Very Satisfied
Enough time was spent with me.
(select)
Not applicable
Very dissatisified
Somewhat dissatisified
Satisfied
Very Satisfied
I received adequate follow up.
(select)
Not applicable
Very dissatisified
Somewhat dissatisified
Satisfied
Very Satisfied
I would refer a friend to the Health Center.
Yes
No
Were you referred elsewhere for additional care?
Yes
No
If you were referred, were you satisfied with the referral?
Yes
No
I have current health care insurance coverage.
Yes
No
This year I have obtained health education pamphlets.
Yes
No
This year I have used the Health Services website.
Yes
No
This year I have attended a health ed./outreach event in the tunnel.
Yes
No
The reason for my visit was
(select)
Illness
Injury
Immunization
Health Information
Medical Treatment
Gender
Male
Female
Optional:
Ethnic background
no response
African American
Asian
Caucasian
Latino
Other
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