1. Your opinion is important to us!

Student Health Services
135 East 12th Street, 2nd Floor
Tel: 212.229.1671 opt 1 Fax: 212.614.7484

Please fill out the following survey to let us know if we are meeting your needs. Feel free to complete this
anonymously. However, if you wish to be contacted by the medical director, please include your name and
contact information.

** Complete questions 1 - 3 ONLY if you DO NOT want your responses to be anonymous.

* 1. Name

* 2. Phone Number

* 3. Email Address

* 4. Age

* 5. Gender (Check one)

* 6. Are you an international student?

* 7. Division

* 8. Academic Level

* 9. Have you ever used Student Health Services?

* 10. Are you aware of the following:

  Yes No
Various services offered by SHS?
Medical office hours?
Medical office location?

* 11. What, if anything, has prevented or discouraged you from using Medical Services?

* 12. When was the last time you used our services? (Check one)

* 13. How did you hear about Medical Services?
(Check all that apply)