Counseling and Health Services

Patient Satisfaction Survey

Gender
Male Female

College Year

Date of Encounter

Which staff members and/or health care provider did you see? (Check all that apply
Office Assistant
Nurse
Nurse Practitioner
Physician

Did you feel you were treated courteously and respectfully by all members of our staff?
Yes No

Comments

Did you feel that your health provider gave you enough information concerning your diagnosis and/or health concerns?
Yes No

Comments

Did you feel that instructions regarding treatment and how to care for yourself were clear and understandable?
Yes No

If no, did you let us know?
Yes No

Did you feel that the issues of your privacy and confidentiality were/are upheld at the Health Center?
Yes No

Comments

Were you satisfied with the amount of time you had to wait for your appointment?
Yes No

Comments

Were you satisfied with the amount of time you had in the appointment with your health provider?
Yes No

Comments

If you were treated for a health problem, were you satisfied with the care you received?
Yes No

Comments

Did you find the Health Center to be clean and appealing to you as a patient?
Yes No

Comments

If you have other suggestions for improving our services or specific comments about your visit, please tell us. If you would like to be contacted regarding a specific concern or issues please include your name and a phone number where you can be reached. Your right to a private vehicle to share your concerns and your right to advocate for yourself are respected.