1.  Enter the date of visit:

-- dd/mm/yy

2.  Name (optional):

Name

3.  Indicate class status:

FR
SO
JR
SR
Other

4.  Indicate the number of times seen by a provider in the health center this year (if O go to question #19 ):

1-3
4-6
7-9
10 or more

5.  I was seen by the following provider(s):

Nurse
Nurse Midwife
Doctor

6.  If seen by the nurse, the amount of time spent with me was:

too short
too long
appropriate

7.  If seen by the Nurse Midwife, the amount of time spent with me was:

too short
too long
appropriate

8.  If seen by the doctor, the amount of time spent with me was:

too short
too long
appropriate

9.  The provider(s) addressed my health concerns:

Yes No

10.  Please indicate which provider did not adequately address your concerns.

11.  The provider gave me clear understanding of my problem and the treatment plan:

Yes No

12.  Please indicate which provider(s) did not clearly state the problem and treatment:

13.  The provider(s) hours in the health center are adequate:

Yes No

14.  Please indicate which provider(s) hours are not adequate:

15.  The Health Center Staff, to include Receptionist, Student Workers, Nurses, Doctor, Nurse Midwife, were all professional:

Yes No

16.  Please indicate which staff member(s) did not meet your standard of professionalism:

17.  My overall experience in the health center was

very positive
positive
negative

18.  Additional comments:

---------------------------------------------------------------------------------

19.  If you have never been seen by a provider in the health center, which of the following do you NOT know about the health center:

The location of the health center
Hour of operation
What services are provided
That you are eligible for services

20.  I rarely or never use health services for the following reasons:

I don't have the school insurance                   My health insurance is not accepted in the health   center                                              I go to my own doctor/nurse practitioner          
I have no health care needs                         I didn't know what services the health center       offered                                             I was concerned about the cost of being seen in   
the health center                                   The health center hours conflict with my            school/work schedule                                other                                             

21.  Please complete this sentence: I have heard that the health center:

22.  I would be likely to use the health center if....