St. Vincent General Hospital District

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

2024 Feedback Survey

1. If you have had a medical visit at St. Vincent Health or St. Vincent Family Health Center in the last 3 years. How would you rate your experience? Scale of 1-5 with 5 as the highest.

Lowest

Highest

Clear selection

2. Would you like to tell us about the experience? What did we do well, or could we have done differently to improve your experience?

3. Do you receive your medical care outside of Lake County?

Yes

Clear selection

4. If you answered “yes” to question 3, why do you travel out of the area for medical care?

5. Is there something we can do, or a service/specialty we can offer so that you would receive your medical care at St. Vincent Health?

6. May we contact you about any comments or concerns you shared in this survey to help us learn about your experience? Please include your contact info.

7. What is your age?

18-24

24-34

35-44

45-54

55-64

65 or over

Clear selection

8. Which race/ethnicity best describes you? (Please choose one.)

American Indian or Alaskan Native

Asian/Pacific Islander

Black or African American

Hispanic/Latine

White/Caucasian

Other:

Clear selection

9. To which gender Identity do you most identify?

Man

Woman

Non-binary

Prefer to self-describe

Clear selection

10. Input your email below if we may send you monthly e-newsletter updates about St. Vincent Health.

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