Medical Homes Post-Questionnaire (Required to Complete Program)

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* 1. Today's date

Date / Time

Date

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* 2. What is your first name?

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* 3. What is your last name?

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* 4. What is your date of birth?

DOB

Date

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* 5. What is your phone number?

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* 6. How do you feel about the way you were treated by City on a Hill staff/ volunteers in the Medical Homes program?

Not good

Okay

Very good

Excellent

Didn't meet with any staff

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* 7. What did you MOST enjoy about the Medical Homes program? Please write your response below.

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* 8. What did you LEAST enjoy about the Medical Homes program? Please write your response below.

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* 9. What suggestions do you have for future programming with the Medical Homes program provided by City on a Hill? Please write your response below.

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* 10. Overall, how would you rank your overall experience with the Medical Homes program? Please select one.

Not good

Okay

Very good

Excellent

Thank you for your participation!