HEALTH SERVICE ASSESSMENT

Today's Date: / /

1.   Please Select One (1) for Each:
                 

2.   Were you treated with respect?
      Yes       No

3.   Did you feel comfortable in asking questions that you
      may have had?
      Yes       Somewhat       No

4.   Did you feel that the practitioner was sensitive to your
      feelings and listened to you?
      Nurse:       Yes       Somewhat       No
      Physician:       Yes       Somewhat       No

5.   Was your condition and treatment explained clearly by the
      Nurse:       Yes       Somewhat       No
      Physician:       Yes       Somewhat       No

6.   Do you feel that your problem was diagnosed correctly?
      Physician:       Yes       Somewhat       No

7.   Do you feel that your needs regarding your specific health
      concerns were met by your visit to the Health Center?
      Yes       Somewhat       No

8.   Did you pick up or receive any printed information during
      this visit?
      Yes       No

9.   Would you return to Student Health Services if you
      experienced another problem?
      Yes       No

10.   Any additional comments: