Bexar County Forms

2. We Value Your Opinion!

   We are committed to providing the highest quality of care to each of our patients. Please help us improve our service by completing this survey regarding your recent Employee Health Clinic visit. Thank you!

4. Employee ID#*
   00000000
5. Provider Name*
   -- Select One --Iyunoluwa Agboola, MDAngela Reilly, MSN, RN, FNP-BCDo Not Remember NameWas not seen by a Provider
6. Appointment Date: *
   Appointment Date:

   Appointment Date:
10. 1. During your most recent visit, did this provider explain things in a way that was easy to understand?*

    1. Yes, definitely

    1. Yes, somewhat

    1. No
12. 2. During your most recent visit, did your provider listen carefully to you?*

    1. Yes, definitely

    1. Yes, somewhat

    1. No
14. 3. Did you talk with this provider about any health questions or concerns?*

    1. Yes

    1. No
16. (If yes) Did this provider give you easy to understand information about these health questions/concerns?*

    1. Yes, definitely

    1. Yes, somewhat

    1. No
18. 4. Did this provider seem to know the important information about your medical history?*

    1. Yes, definitely

    1. Yes, somewhat

    1. No
20. 5. Did this provider show respect for what you had to say?*

    1. Yes, definitely

    1. Yes, somewhat

    1. No
22. 6. Did this provider spend enough time with you?*

    1. Yes, definitely

    1. Yes, somewhat

    1. No
24. 7. How would you rate this provider?*
    -- Select One --0 - Poor12345 - Fair678910 - Excellent

    Using any number from zero to ten, where zero is the worst provider and ten is the best provider.
26. 8. Would you recommend this provider to other County employees?*

    1. Yes, definitely

    1. Yes, somewhat

    1. No
28. What is the one thing we could have done better to improve your experience at the Employee Health Clinic?
    (Optional)

32. If your concerns need immediate attention, please fill out the following and you will be contacted.

34. Name:
35. Phone:
36. Email:
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field