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Date of visit:
Test performed:
1. Did you have any trouble finding the clinic?
Yes
No
2. Were you attended to promptly, and courteously upon your arrival?
Yes
No
3. Were you taken to the exam room in a reasonable amount of time?
Yes
No
4. Was the test explained to you before it was started?
Yes
No
5. Were your questions answered satisfactorily?
Yes
No
6. Were you treated with courtesy and respect at all times?
Yes
No
7. Was your privacy respected during your visit?
Yes
No
8. Did you find the atmosphere of the clinic pleasant?
Yes
No
9. Would you return to the clinic again for testing?
Yes
No
10. If yes, was it informative and helpful?
Yes
No
GENERAL COMMENTS OR SUGGESTIONS FOR IMPROVEMENT
