* 1. What is today's date?

* 2. What time was your appointment?

* 3. What physician, nurse practitioner or clinic specialist are you seeing?

* 4. APPOINTMENT - How satisfied were you with the:

  Very Satisfied Satisfied Dissatisfied Does Not Apply
Ease of making an appointment
Appointment Availability
Appointment Reminder
Check-In Process
Courtesy of Staff
Wait time in the reception area
Obtaining medical and vital signs