Medical Clinic Temperature Feedback Survey Form
Please share your feedback about the temperature comfort during your recent visit. Your input helps us improve the clinic environment for everyone.
Full Name
*
First Name
Last Name
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which area or room did you spend most of your time in?
*
Please Select
Waiting Room
Exam Room
Lobby
Restroom
Other
What time of day was your visit?
*
Please Select
Morning
Afternoon
Evening
How comfortable was the temperature in the clinic?
*
Very comfortable
Comfortable
Neutral
Uncomfortable
Very uncomfortable
Please rate the temperature in the clinic.
*
1
2
3
4
5
Did you experience any of the following temperature issues?
*
Too cold
Too warm
Drafts
Temperature varied between rooms
No issues
Other
If you experienced an issue, please describe it.
Do you have any suggestions for improving temperature comfort?
Email address (optional, if you would like a follow-up)
example@example.com
Submit Feedback
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