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* 1. Date of Visit

Date

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* 2. Language

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* 3. Department

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* 4. Provider

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* 5. Which age bracket do you fall into?

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* 6. I was able to speak with a Call Center Agent within 0-5 minutes of calling in.

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* 7. I was involved in decision-making about my own health and well-being .

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* 8. I am confident I can get medical help from Ravenswood Family Health Center between appointments.

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* 9. Overall, I was satisfied with my visit.

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* 10. From the time you were checked in, how long did you wait until you were taken to exam room?

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* 11. For today's visit, I made my appointment:

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* 12. Does lack of transportation prevent you from seeking care?  

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* 13. Do you need help with transportation to the clinic?

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* 14. Do the clinic hours prevent you from seeking care?

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* 15. What time do you prefer for you and your family? Choose all that apply.

  Monday Tuesday Wednesday Thursday Friday Saturday
Morning  8:00am - 12:00pm
Afternoon  1:00pm - 5:00pm
Evening 5:00pm - 7:00pm

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* 16. Are you able to pay the discounted amount requested for care?

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* 17. Does the discounted fee prevent you from seeking care?

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* 18. Are there any comments you would like to make?  

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