Healthcare Interaction Assessment
Please complete this assessment regarding your recent healthcare interaction.
Full Name
First Name
Last Name
Date of Interaction
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Healthcare Provider Name
How would you rate the quality of care you received?
1
2
3
4
5
Was the healthcare provider attentive to your needs?
Yes
No
Somewhat
Was the facility clean and comfortable?
Yes
No
Somewhat
Please provide any additional comments or suggestions.
Submit
Should be Empty: