State Your Health

Patient Survey


We take your comments seriously and appreciate your input. This survey is completely confidential. If you would like a representative to contact you about your experience at the student health center, please enter your email address and/or phone number at the bottom of the survey.

Date of Visit:

Have you previously been to the Student Health Center?
Yes
No

If Yes, when?

How satisfied were you with the services you used?
(if you did not use a service select N/A)

Travel Clinic
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Physical Therapy
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Allergy Clinic
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Nutritionist
 Excellent  Good Fair Poor N/A
excelent good fair poor no

General Medical
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Health Education
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Referral Coordinator
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Receptionist/Check-in
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Administrative Offices
 Excellent  Good Fair Poor N/A
excelent good fair poor no

X-ray
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Pharmacy
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Laboratory
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Insurance Office
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Medical Records
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Appointments
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Prior to your visit, you heard the services at the Student Health Center were:
 Excellent  Good Fair Poor N/A
excelent good fair poor no

How would you rate the following?
Availability of appointments
 Excellent  Good Fair Poor N/A
excelent good fair poor no
Availability of clinic hours
 Excellent  Good Fair Poor N/A
excelent good fair poor no
Waiting time on the day of your visit
 Excellent  Good Fair Poor N/A
excelent good fair poor no
Courtesy of staff
 Excellent  Good Fair Poor N/A
excelent good fair poor no
Medical service provided
 Excellent  Good Fair Poor N/A
excelent good fair poor no
Cleanliness of facility
 Excellent  Good Fair Poor N/A
excelent good fair poor no
Health education provided
 Excellent  Good Fair Poor N/A
excelent good fair poor no
Overall services
 Excellent  Good Fair Poor N/A
excelent good fair poor no

Would you recommend the Student Health Center to other students?
Yes
No

Was there anyone at the Student Health Center who you feel acted inappropriately?
Yes
No

What is your gender?
Female
Male

What is your classification?
Private Patient
Freshman
Sophomore
Junior
Senior
Graduate

By what method were you notified of this survey?
Card with survey web address
Paper survey in clinic
Email survey

Please indicate your preference for receiving this survey
Card with survey web address
Paper survey in clinic
Email survey

Comments and Suggestions (Please feel free to elaborate on any of your responses on this survey)

Name:
Phone Number:
Email Address:
  



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