Medical Survey Form
Please complete the Medical Survey Form to help us improve healthcare experiences. Your responses are anonymous and valuable.
Age Range
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 and over
Gender
*
Female
Male
Non-binary
Prefer not to say
Other
Overall, how would you rate your current health?
*
1
2
3
4
5
How often do you visit a healthcare provider?
*
Once a year or less
2-3 times a year
4 or more times a year
How satisfied are you with the quality of medical care you have received in the past year?
*
Very dissatisfied
1
2
3
4
Very satisfied
5
1 is Very dissatisfied, 5 is Very satisfied
Please indicate your agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel informed about my health.
1
2
3
4
5
Medical staff communicate clearly.
6
7
8
9
10
Appointments are easy to schedule.
11
12
13
14
15
How easy was it to access healthcare services when you needed them?
*
Very difficult
1
2
3
4
Very easy
5
1 is Very difficult, 5 is Very easy
If you have used telemedicine or virtual care in the past year, how would you rate your experience?
1
2
3
4
5
What is one thing you would improve about your healthcare experience?
Any additional comments or suggestions?
Submit Medical Survey
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