Satisfaction Survey

Date of Visit: Time of Visit:
Gender: Age:
Place of Residence Type of Visit:
Who provided your service?

Did you walk in to make the appointment or call?
Walked In
Called

Check the primary reason(s) that you use the Health and Wellness Center:

Cost Previous Visit Satisfaction
Convenience Suggested by a Friend
Confidence in Staff Suggested by Family
Other

What was your approximate wait time for the scheduling of your appointment?

If you were scheduling an appointment for a medical visit and were not seen on the same day, please explain why.

How long did you wait in the reception area?

How did you hear about the services offered through the Health and Wellness Center?

Orientation Flyers
Brochures Friends
Posters Web site
Student Newspaper Student E-News
Other

I was satisfied with services provided by the following:

Receptionist Medical Assistant
Nurse Practitioner Nursing Staff
Laboratory Health Educator
Counseling Disability Services
AWARE Counselor Physician
Psychiatrist Physician Assistant
Comments:

The thoroughness of discussing my problems/treatments were met:

Physician Nurse Practitioner
Health Educator Mental Health Counselor
RN AWARE Counselor
Disability Counselor Psychiatrist
Physician Assistant  
Comments:

Rate your level of satisfaction with the following:

1. Overall services you received
2. Timeliness with which you were seen
3. Comfort level in discussing private matters
4. Courtesy of support staff (receptionist/medical assistant)
5. Professionalism of your clinician
6. Provision of information regarding my area of concern


The services provided will help with: N/A Strongly Agree Agree Neutral Disagree Strongly Disagree
Maintaining class attendance
Improving my health (physical or emotional)
Decision making regarding risk factors (Alcohol and other drugs, sexual decision-making, etc.)
Staying healthy and staying in school
Academic performance

Additional Comments:

Please list any additional Health and Wellness related services that you would like to see the Center provide:

Security Code:
Please type the following security code in the box below:14562

Please feel free to contact the Director of the Health and Wellness Center, Dr. Joy Himmel, with questions or to provide additional input. Dr. Himmel can be contacted at 814-949-5540 or by e-mail at JYH1@psu.edu.