Patient Survey Patient Survey (If applicable) Have you had a PAP smear? Yes No Not Applicable If NO, why?(Required) Are you up to date with your immunizations? Yes No If NO, why?(Required) (If applicable) Have you had a mammogram? Yes No Not Applicable If NO, why?(Required) Have you had a physical in the last year? Yes No If NO, why?(Required) Do you smoke? Yes No Prefer not to answer (If applicable) Have you had a colon screening? Yes No Not Applicable Have you felt sad or depressed? Yes No Have you been to the dentist in the past year? Yes No If No, why? On a scale of 1 - 5, how easy was it to schedule an appointment?123451 being horrible, 5 being excellentHow did our Outreach staff do in assisting you when coming to the clinic?123451 being horrible, 5 being excellentIf you have used KCHC transportation in the past, how would you rate our service?123451 being horrible, 5 being excellentIs there anything you would like to learn more about, or do you have any questions regarding the following topics? Diabetes STD's Smoking Obesity Nutrition Blood Pressure Depression Alzheimer's Pregnancy Any additional Comments:EmailThis field is for validation purposes and should be left unchanged.
