JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Free Clinics Survey
Sign in to Google
to save your progress.
Learn more
Have you been to a free clinic before?
Yes
No
Clear selection
How old are you?
Under 16
17-21
22-30
31-40
41-50
51-60
Older than 60
Clear selection
Which state is the free clinic located in?
Your answer
Please rate your experience in the free clinic.
Bad
1
2
3
4
5
Excellent
Clear selection
Did the clinic have adequate resources or appear to be underfunded?
Adequate resources
Underfunded
Clear selection
How were you treated by staff and doctors in the clinic? Rate how you were treated by staff and doctors in the clinic.
Very well
Adequately
Poorly
Clear selection
Do you believe the doctors were engaged when you brought up a comment or concern?
Yes
No
Clear selection
Did you experience discrimination while in the free clinics?
Yes
No
Clear selection
Do you believe your health improved because of treatments given in these clinics?
Yes
No
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
