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  General
 
 
 
1.
*
  mm/dd/yyyy
 
 
 
2.
Gender:*
 
 
 
 
3.
Are you:*
 
 
 
 
4.
Ethnicity:*
 
 
 
 
 
 
 
 
5.
Student Classification:*
 ( Mark all that apply )   Select at least 1 response.
 
 
 
 
 
 
 
 
 
 
6.
How long did you wait before you saw a doctor or nurse practitioner?*
 
 
 
 
 
 
 
 
 
  The Receptionist
 
 
 
7.
Maintained a pleasant waiting room atmosphere
 
 
 
 
8.
Was interested in helping me
 
 
 
 
9.
Was approachable and easy to talk with
 
 
 
 
10.
Was courteous, polite and helpful
 
 
 
 
11.
Provided information that was helpful and clear
 
 
 
 
 
 
 
  The Nurse
 
 
 
12.
Was caring
 
 
 
 
13.
Helped me make informed health decisions
 
 
 
 
14.
Was approachable and easy to talk with
 
 
 
 
15.
Was interested in helping me
 
 
 
 
16.
Allowed sufficient time to discuss issues or problems
 
 
 
 
 
 
 
  The Medical Doctor/Nurse Practitioner
 
 
 
17.
Was caring
 
 
 
 
18.
Was approachable and easy to talk with
 
 
 
 
19.
Allowed sufficient time to discuss issues or problems
 
 
 
 
20.
Helped me make informed health decisions
 
 
 
 
21.
Was interested in helping me
 
 
 
 
 
 
 
  The Laboratory Staff
 
 
 
22.
Was caring
 
 
 
 
23.
Was approachable and easy to talk with
 
 
 
 
24.
Allowed sufficient time to discuss issues or problems
 
 
 
 
25.
Was interested in helping me
 
 
 
 
 
 
 
  The X-ray Staff
 
 
 
26.
Was caring
 
 
 
 
27.
Was approachable and easy to talk with
 
 
 
 
28.
Allowed sufficient time to discuss issues or problems
 
 
 
 
29.
Was interested in helping me
 
 
 
 
 
 
 
30.

 
 
 
  Done