1.  Date of visit: 

2.  Class Status:     Choose one Freshman Sophomore Junior Senior Graduate         

3.  Please rate your overall visit to the Student Health Center.

         Poor        Fair        Satisfactory        Good        Excellent 

4.  Mark the provider you saw during your visit.

        Secretary    Lab    Nursing    Physician    Nurse Practitioner   

5.  Have you visited the Student Health Center before?

        Yes    No       

6.  What kind of comment would you like to send?

        Complaint    Problem    Suggestion    Praise

7.  Please describe the reason for your visit to the health center.

8.  Additional comments are welcomed below.

9.  If you you would like to be contacted regarding your comment, question, or suggestion, please fill in the following information:

    Name: 

    Email: