2017 CHOICES Patient Satisfaction Survey

Thank you for choosing CHOICES for your reproductive and sexual health services. In order to improve our services, please take a moment to fill out this SHORT survey. Those who complete the survey will receive a CHOICES gift!

As a reminder, all of your responses are anonymous. If you have any questions, please feel free to contact us at 901-274-3550 ext. 104.

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* 1. How likely would you be to recommend Choices. Memphis Center for Reproductive Health, to a friend for reproductive or/and sexual health services.

0. Not at all likely

10.Very likely

0. Not at all likely

10.Very likely

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* 2. Please tell us why you gave this answer.

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* 3. What do you consider your sexual orientation?

Straight

Bisexual

Gay

Lesbian

Pansexual

Asexual

Other (please specify)

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* 4. What do you consider your gender?

Female (Cisgender Woman)

Male (Cisgender Man)

Transgender Man

Transgender Woman

Nonbinary/ Gender Nonconforming/ Genderqueer

Other (please specify)

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* 5. What do you consider your race/ethnicity?

Asian

Black

Hispanic

White

Other: (please specify)

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* 6. What is your current zip code?

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* 7. How did you hear about CHOICES?

Google

Event/ Health Fair

La Prensa Latina

Memphis Flyer

Social Media: Facebook/Twitter/ Instagram

Radio (Ambiente 1030)

Cards/ Flyers

Friend/Family

Other: Please tell us how you heard about us.

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* 8. What type of medical services did you receive at CHOICES?

Medical Abortion (non-surgical form of abortion in which the woman takes pills containing Mifepristone)

Surgical Abortions (involves dilating the opening to the uterus (cervix) and placing a small suction tube into the uterus)

Birth control

HIV Testing

STI Testing

PAP smears and gynecological services

Pregnancy testing

Fertility Assistance

PrEP Services

PEP Services

Hormone Replacement Therapy

Other: Please tell us what services you received.

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* 9. Please rate your knowledge BEFORE coming to Choices about your sexual health.

0 - I had NO knowledge about my sexual health options.

1 - I had a little knowledge about my sexual health options but mostly just questions.

2 - I had a good bit of knowledge about my sexual health options but some questions.

3 - I had an extensive knowledge about my sexual health options and had no questions.

0 - I had NO knowledge about my sexual health options.

1 - I had a little knowledge about my sexual health options but mostly just questions.

2 - I had a good bit of knowledge about my sexual health options but some questions.

3 - I had an extensive knowledge about my sexual health options and had no questions.

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* 10. Please rate your knowledge AFTER coming to Choices about your sexual health.

0 - I had NO knowledge about my sexual health options.

1 - I had a little knowledge about my sexual health options but mostly just questions.

2 - I had a good bit of knowledge about my sexual health but some questions.

3 - I had an extensive knowledge about my sexual health options and had no questions.

0 - I had NO knowledge about my sexual health options.

1 - I had a little knowledge about my sexual health options but mostly just questions.

2 - I had a good bit of knowledge about my sexual health but some questions.

3 - I had an extensive knowledge about my sexual health options and had no questions.

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* 11. Have you done any of the following activities since your visit to CHOICES?

	Yes	No	Sometimes	Not Applicable
I have consistently used birth control since my visit to Choices.	I have consistently used birth control since my visit to Choices. Yes	I have consistently used birth control since my visit to Choices. No	I have consistently used birth control since my visit to Choices. Sometimes	I have consistently used birth control since my visit to Choices. Not Applicable	I have consistently used birth control since my visit to Choices.
I have shared what I learned about birth control and/or sexual health options with a friend.	I have shared what I learned about birth control and/or sexual health options with a friend. Yes	I have shared what I learned about birth control and/or sexual health options with a friend. No	I have shared what I learned about birth control and/or sexual health options with a friend. Sometimes	I have shared what I learned about birth control and/or sexual health options with a friend. Not Applicable	I have shared what I learned about birth control and/or sexual health options with a friend.
I have had UNprotected sex.	I have had UNprotected sex. Yes	I have had UNprotected sex. No	I have had UNprotected sex. Sometimes	I have had UNprotected sex. Not Applicable	I have had UNprotected sex.
I have consistently used a method of birth control.	I have consistently used a method of birth control. Yes	I have consistently used a method of birth control. No	I have consistently used a method of birth control. Sometimes	I have consistently used a method of birth control. Not Applicable	I have consistently used a method of birth control.

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* 12. Is there anything you would suggest to improve our center?

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* 13. Would you be willing to talk about your visit at CHOICES in more detail?

YES

If yes, please add contact information in box (name, email, contact number)

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* 14. CHOICES does not discriminate against any person on the basis of race, age, gender identity or expression, sexual orientation, body size, religion, cultural heritage, or disability. Please report any instances of discrimination to Choices by calling 901-274-3550 ext. 104. Or in the box provided below.