Background Questions:

Patient's Sex:    
What is your enrollment classification?    
Date of Visit (Approximate):   
Patient's First Visit Here:
Did you see a Physician, Advanced Practice Nurse (APN), OB/GYN ANP?

Rate the services you received from our practice. Space is provided for both positive and negative comments.
 Access to Care: Very Poor   Poor Fair Good Very Good
Ease of scheduling appointment
Courtesy of person who scheduled your appointment
Our promptness in returning your phone calls
Convenience of office hours
Comments: (describe positive or negative experience)

 During Your Visit: Very Poor         Poor Fair Good Very Good
Courtesy of staff in the registration area
Length of wait before going to exam room
Comfort and pleasantness of the waiting area
Friendliness/courtesy of the support staff
Concern the support staff showed for your problem
Waiting time in exam room before being seen by the provider
Comments: (describe positive or negative experience)

 Your Care Provider: Very Poor         Poor Fair Good Very Good
During your visit, your care was provided primarily by a physician or advanced nurse practitioner (APN). Please answer the following questions with that provider in mind.

Friendliness/courtesy of the care provider
Explanations the care provider gave for your questions or problem
Efforts to include you regarding decisions about your treatment
Information the care provider gave you about medications (if any)
Instructions the care provider gave you about follow-up care (if any)
Degree to which care provider talked using words you could understand
Amount of time care provider spend with you
Your confidence in this care provider
Likelihood of you recommending this care provider to others
Comments: (describe positive or negative experience)

 Overall Assessment: Very Poor         Poor Fair Good Very Good
Our concern for your privacy
Overall cheerfulness of our practice
Overall cleanliness of our practice
Likelihood of recommending our practice to others
Overall rating of care received during your visit
Comments: (describe positive or negative experience)


If you had a particularly positive or a particularly unpleasant/negative experience in Student Health Services and would like to discuss it with someone, please call Michael Scott Batson, LVN (Clinic Staff Supervisor) at 214-645-7292.