Student Health Survey

How much of an impact did your illness have on your academic performance?

Severe

Moderate

Mild

None

Are you: Male Female

Please select how well you think we are doing in the following areas:

5=Great

4=Good

3=OK

2=Fair

1=Poor

Ease of getting care

Ability to get in to be seen	5	4	3	2	1
Hours Center is open	5	4	3	2	1
Convenience of Center's location	5	4	3	2	1
Prompt return on calls	5	4	3	2	1

Waiting

Time in waiting room	5	4	3	2	1
Time in exam room	5	4	3	2	1
Waiting for tests to be performed	5	4	3	2	1
Waiting for test results	5	4	3	2	1

Physician or Nurse:

Check the name of your Care Provider:

Listens to you	5	4	3	2	1
Takes enough time with you	5	4	3	2	1
Explains what you want to know	5	4	3	2	1
Gives you good advice and treatment	5	4	3	2	1
Friendly and helpful to you	5	4	3	2	1
Answers your questions	5	4	3	2	1

All Others

Friendly and helpful to you	5	4	3	2	1
Answers your questions	5	4	3	2	1

Payment

Facility

Neat and clean building	5	4	3	2	1
Ease of finding where to go	5	4	3	2	1
Comfort and Safety while waiting	5	4	3	2	1
Privacy	5	4	3	2	1

Confidentiality

Keeping my personal information private

The likelihood of referring other students to us:

Do you consider this center your regular source of care?	Yes	No
What do you like best about our center?
What do you like least about our center?
Suggestions for improvement?

Academics

How successfully did we identify an appointment time that worked with your class schedule?

To what extent did your treatment through Student Health Services speed you return to the classroom?

If you would like our staff to contact you, please include your name & phone number so someone may reach you.