2. Which clinic did you or your child visit today?*

   1. Maternal Health
   2. Child Health
   3. Family Planning
   4. STD (Statesville Location)
   5. Immunizations (Statesville Location)

   1. Immunization (Mooresville Location)
   2. Dental
   3. WIC (Statesville Location)
   4. WIC (Mooresville Location)
4. How did you find out about us?*

   1. Class at school
   2. Health Fair/ Community Presentation
   3. Family member, friend, or co-worker
   4. TV
   5. Radio
   6. Internet

   1. Newspaper
   2. Health Department brochure
   3. Other Health Department Clinic
   4. I have used this service before
   5. Doctor or worker in hospital
   6. other
6. Was the staff polite and professional

   1. Yes
   2. No
8. How was the length of your visit today?

   1. Too short
   2. Too long
   3. Enough time
10. Was the waiting area and exam room clean and in good condition?*

    1. Yes
    2. No
    3. Exam room was dirty
    4. Waiting room was dirty
12. Overall, were you satisfied with your visit today?*

    1. Yes
    2. No
14. Please share any comments or suggestions about what we can do better*
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