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Medical Patient Survey
1.
What department where you seen in today?
Maternal/Family Planning
Pediatrics
Adult
X-ray/Lab/Mammogram
Other (please specify)
2.
Did you have a scheduled appointment today?
Yes
No
3.
Is this clinic your sole provider for medical care?
Yes
No
4.
Where do you go for health care when the clinic is closed?
5.
Please respond to how you agree with the following statements:
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
N/A
When you called the clinic, the person who answered the phone was prompt.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
N/A
Your check in process was efficient.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
N/A
The clinician staff was friendly to you.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
N/A
All of your questions/concerns were answered by your Doctor/Midwife/Nurse Practitioner.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
N/A
Overall, you were satisfied with your experience at the clinic today.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
N/A
How reasonable was your wait time for the services you received?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
N/A
6.
Please use the space below to add any comments you may have.
Current Progress,
0 of 6 answered