Patient Satisfaction Form WPI students who have utilized any of the programs or services offered by Student Health Services are encouraged to take the Patient Satisfaction Survey to provide comments, ratings, and more information about their experience. Please answer the following questions about your experience with us: Have you utilized Health Services within the last year? Have you utilized Health Services within the last year? Yes No On a scale of 1 to 5 (1 being very difficult and 5 being very easy), how was your experience making an appointment in Health Services? On a scale of 1 to 5 (1 being very difficult and 5 being very easy), how was your experience making an appointment in Health Services? 1 2 3 4 5 In the box below please comment on what Health Services could do to improve your experience at making appointments. Additional Questions: If our Receptionist provided you with service, please indicate your level of satisfaction with the Receptionist (1 being unsatisfied and 5 very satisfied). 1 2 3 4 5 Were you greeted in a welcoming and helpful manner by our staff? (1 being very negative and 5 very positive) 1 2 3 4 5 During your most recent visit, did you see your healthcare provider in a timely manner of your appointment time? Wait time includes time spent in the waiting room and exam room. Yes No If not, how long was the wait from the scheduled time of appointment? < 5 minutes 5 -15 minutes > 15 minutes During your most recent visit if a Nurse assessed or treated you, please indicate your level of satisfaction with the care provided (1 being unsatisfied and 5 very satisfied). 1 2 3 4 5 N/A During your most recent visit if a Nurse Practitioner assessed or treated you, please indicate your level of satisfaction with the care provided (1 being unsatisfied and 5 very satisfied). 1 2 3 4 5 N/A During your most recent visit, if a Physician assessed or treated you, please indicate your level of satisfaction with the care provided (1 being unsatisfied and 5 being very satisfied). 1 2 3 4 5 N/A Indicate your level of satisfaction with the attention your Caregiver showed to your current condition and your healthcare beliefs (1 being unsatisfied and 5 very satisfied). 1 2 3 4 5 Indicate your level of satisfaction with instructions and health education regarding diagnosis/medications/lab tests/X-ray/referrals you received during your most recent visit (1 being unsatisfied and 5 very satisfied). 1 2 3 4 5 Indicate your level of satisfaction with instructions you received about how to take care of yourself and if and when you should return to Health Services (1 being not satisfied and 5 very satisfied). 1 2 3 4 5 Were you notified of your lab results or x-ray results via phone call or secure message? Yes No Comments Were you satisfied with the cleanliness of Health Services (1 being unsatisfied and 5 very satisfied)? Were you satisfied with the cleanliness of Health Services (1 being unsatisfied and 5 very satisfied)? 1 2 3 4 5 General Comments IF YOU WISH TO IDENTIFY YOURSELF FOR A FOLLOW-UP INTERVIEW, PLEASE LEAVE YOUR INFORMATION BELOW: Name Email Phone Number Date of visit Appointment with Currently, what country are you physically present in? * - Select -United States of AmericaAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas (the)BahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean Territory (the)Brunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman Islands (the)Central African Republic (the)ChadChileChinaChristmas IslandCocos (Keeling) Islands (the)ColombiaComoros (the)Congo (the Democratic Republic of the)Congo (the)Cook Islands (the)Costa RicaCôte d\'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican Republic (the)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (the) [Malvinas]Faroe Islands (the)FijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern Territories (the)GabonGambia (the)GeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (the)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (the Democratic People's Republic of)Korea (the Republic of)KuwaitKyrgyzstanLao People's Democratic Republic (the)LatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia (the former Yugoslav Republic of)MadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall Islands (the)MartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (the Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands (the)New CaledoniaNew ZealandNicaraguaNiger (the)NigeriaNiueNorfolk IslandNorthern Mariana Islands (the)NorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippines (the)PitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian Federation (the)RwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudan (the)SurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan (R.O.C)TajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos Islands (the)TuvaluUgandaUkraineUnited Arab Emirates (the)United Kingdom of Great Britain and Northern Ireland (the)United States Minor Outlying Islands (the)UruguayUzbekistanVanuatuVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern Sahara*YemenZambiaZimbabwe By providing the information requested in this form, you are consenting to WPI’s use of the provided information for the purpose for which the form is being used. 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