Medical Clinic Feedback

Visit Information

Date of Visit

Reason for Visit

🤕 Injury 🤒 Illness 🩺 Routine Check 💊 Medication 🚨 Emergency 🧠 Mental Health 💬 Other

Work Area

Is this work-related?

Yes No

Access & Timeliness

How quickly were you seen?

Immediate Quick Acceptable Slow Very Slow

Was the clinic easily accessible?

Yes No

Were you seen at a reasonable time?

Yes No

Quality of Care

Staff Professionalism

1 2 3 4 5 PoorExcellent

Was your treatment explained to you?

Yes Partially No

Did you feel listened to?

Yes Partially No

Was your privacy maintained?

Yes No

Was the treatment appropriate?

Yes Unsure No

Facilities & Resources

Cleanliness Rating

1 2 3 4 5 PoorExcellent

Were required medications available?

Yes Partially No

Overall facility adequacy

1 2 3 4 5 PoorExcellent

Outcomes & Follow-up

Were you given follow-up instructions?

Yes No N/A

Were you referred for further care?

Yes No Not Needed

Are you fit to return to work?

Yes No Sick Bay N/A

Overall Assessment

Overall Experience Rating

1 2 3 4 5 Very PoorExcellent

Would you confidently use this clinic again?

Yes Maybe No

Should this require urgent management review?

Yes — Urgent No

Additional Comments (optional)

Your Identity

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