Patient Experience Survey English Español (Estados Unidos) Question Title Question Title * 1. Date Date / Time Date Question Title * 2. Gender: Female Male Transgender Question Title * 3. Race/Ethnicity: Black/African American Hispanic Native American White Other (please specify) Question Title * 4. Age Under 18 18-24 25-34 35-44 45-54 55-64 65+ Question Title * 5. First Choice Location Alameda Alamosa Belen Edgewood Los Lunas North Valley South Broadway South Valley Question Title * 6. Is this your FIRST appointment with any provider at this clinic? Yes No Next
