Annual Check-Up Experience Questionnaire
Please share your feedback about your recent annual healthcare check-up to help us improve our services.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Your Annual Check-Up
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you schedule your appointment?
*
Online portal
Phone call
Walk-in
Other
Please rate the following aspects of your visit:
*
Rows
Excellent
Good
Fair
Poor
Ease of scheduling
1
2
3
4
Check-in process
5
6
7
8
Wait time
9
10
11
12
Professionalism of staff
13
14
15
16
Cleanliness of facility
17
18
19
20
Clarity of information provided
21
22
23
24
How would you rate your overall satisfaction with your annual check-up?
*
1
2
3
4
5
Did you receive clear explanations regarding your health status and next steps?
*
Yes, completely clear
Somewhat clear
Not clear
Would you recommend our facility to others?
*
Yes
No
What could we improve to enhance your annual check-up experience? (Optional)
Submit Feedback
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