1.Why did you choose to come to the Medical Clinic?

Convenient 

Affordable

Recommended

Quality of Care

Other (please specify)

2.How did you hear about us?

I was already a patient

Family and friends

Hands of Hope Medical Clinic

A community resource (day care, church, food pantry, etc.)

Another government agency (Social Services, Schools, Courts, etc.)

Employer

My primary care provider

An urgent care

Other (please specify)

3.Why are you here today?

Child Health

Family Planning

Maternal Health

Immunizations Only

Adult Health

Other Services

4.Please rate our customer service and facility?

Excellent

Good

Poor

Check In/Check Out

Excellent

Good

Poor

Nurses

Excellent

Good

Poor

Doctors

Excellent

Good

Poor

Cleanliness

Excellent

Good

Poor

Appearance

Excellent

Good

Poor

5.How satisfied are you with the ability to access care (appointment availability)?

Not satisfied

Neutral

Satisfied

Very Satisfied

N/A

6.How well were you able to understand information provided by the healthcare provider? 

Not at all

Somewhat

Good

Very Good

N/A

7.Are the clinic hours good for you?

Yes

No

8.Which of the following do you like?

Written Instruction

Verbal Instruction

Classes

9.Overall, how was our service?

Excellent

Good

Poor

10.If it is poor can you tell us why?

11.How long were you at the clinic today?

less than 30 minutes

between 30 minutes and 1 hour

between 1 hour and 1 1/2 hours

between 1 1/2 hours and 2 hours

more than 2 hours 

12.Other comments: