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2. Have you or a family member ever visited our Health Unit? We want to hear from you! We are asking our community to take a few minutes to share their experiences and feedback. Your input helps us measure satisfaction, better understand community needs, improve our current services, and plan for the future. This survey is completely anonymous — no identifying information is collected. Your honest feedback makes a difference!

4. How satisfied were you with your overall experience at our Health Unit?*

   1. 5 - Very Satisfied
   2. 4 - Satisfied
   3. 3 - Neutral
   4. 2 - Dissatisfied
   5. 1 - Very Dissatisfied
5. How friendly/helpful was the staff throughout your visit?*

   1. Very Friendly/ Very Helpful
   2. Friendly/Helpful
   3. Neutral
   4. Not Friendly/Not Helpful
6. How would you rate the overall quality of care provided by our staff?*

   1. Excellent
   2. Good
   3. Fair
   4. Poor
8. What did you like most about your visit?*
10. How would you describe your experience at our Health Unit?*
12. What services would you like our Health Unit to offer in the future?*
14. Is this your first time using our Health Unit?*

    1. First Time Visitor
    2. Returning Visitor
15. Are you a West Baton Rouge Parish Resident?*

    1. Yes
    2. No
16. Were you able to get an appointment at a reasonable time?*

    1. Yes
    2. No
18. What service(s) did you use today or in the past?*

    1. WIC
    2. Immunization
    3. Family Planning
    4. STD/STI Screening
    5. Pregnancy Test
    6. Adult Health Screening
    7. Other
19. How well did our staff explain your medications or follow-up care instructions?*

    1. Very Well
    2. Well
    3. Poorly
    4. Very Poorly
    5. Not Applicable
20. Patient Age Range*

    1. Under 18
    2. 18 - 24
    3. 25 - 34
    4. 35 - 44
    5. 45 - 54
    6. 55 - 64
    7. 65+
    8. Prefer not to say
22. How did you hear about the Health Unit?*

    1. Facebook
    2. Instagram
    3. Friend
    4. Family
    5. Doctor Referral
    6. Website
    7. Community Event
    8. Other
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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