Medical Patient Survey

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* 1. What department where you seen in today?

Maternal/Family Planning

Pediatrics

Adult

X-ray/Lab/Mammogram

Other (please specify)

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* 2. Did you have a scheduled appointment today?

Yes

No

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* 3. Is this clinic your sole provider for medical care?

Yes

No

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* 4. Where do you go for health care when the clinic is closed?

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* 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.	When you called the clinic, the person who answered the phone was prompt. Strongly Disagree	When you called the clinic, the person who answered the phone was prompt. Disagree	When you called the clinic, the person who answered the phone was prompt. Neutral	When you called the clinic, the person who answered the phone was prompt. Agree	When you called the clinic, the person who answered the phone was prompt. Strongly Agree	When you called the clinic, the person who answered the phone was prompt. N/A
Your check in process was efficient.	Your check in process was efficient. Strongly Disagree	Your check in process was efficient. Disagree	Your check in process was efficient. Neutral	Your check in process was efficient. Agree	Your check in process was efficient. Strongly Agree	Your check in process was efficient. N/A
The clinician staff was friendly to you.	The clinician staff was friendly to you. Strongly Disagree	The clinician staff was friendly to you. Disagree	The clinician staff was friendly to you. Neutral	The clinician staff was friendly to you. Agree	The clinician staff was friendly to you. Strongly Agree	The clinician staff was friendly to you. N/A
All of your questions/concerns were answered by your Doctor/Midwife/Nurse Practitioner.	All of your questions/concerns were answered by your Doctor/Midwife/Nurse Practitioner. Strongly Disagree	All of your questions/concerns were answered by your Doctor/Midwife/Nurse Practitioner. Disagree	All of your questions/concerns were answered by your Doctor/Midwife/Nurse Practitioner. Neutral	All of your questions/concerns were answered by your Doctor/Midwife/Nurse Practitioner. Agree	All of your questions/concerns were answered by your Doctor/Midwife/Nurse Practitioner. Strongly Agree	All of your questions/concerns were answered by your Doctor/Midwife/Nurse Practitioner. N/A
Overall, you were satisfied with your experience at the clinic today.	Overall, you were satisfied with your experience at the clinic today. Strongly Disagree	Overall, you were satisfied with your experience at the clinic today. Disagree	Overall, you were satisfied with your experience at the clinic today. Neutral	Overall, you were satisfied with your experience at the clinic today. Agree	Overall, you were satisfied with your experience at the clinic today. Strongly Agree	Overall, you were satisfied with your experience at the clinic today. N/A
How reasonable was your wait time for the services you received?	How reasonable was your wait time for the services you received? Strongly Disagree	How reasonable was your wait time for the services you received? Disagree	How reasonable was your wait time for the services you received? Neutral	How reasonable was your wait time for the services you received? Agree	How reasonable was your wait time for the services you received? Strongly Agree	How reasonable was your wait time for the services you received? N/A

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* 6. Please use the space below to add any comments you may have.