PCAACs Patient Feedback Form
Praana Charitable Allergy Asthma Clinic (PCAAC)  -- This Patient Feedback form is to used upon completion of  treatment for patients seeking services at a PCAAC.  We thank you, our patients, for your participation.  The data collected will be analyzed and used to improved the medical services offered at PCAACs.
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Date and Time of Appointment *
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Time
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City/Town and State where this Praana Charitable Clinic is located. *
Patient's Current Age *
Patient's Sex *
Patient's Occupation *
What is your monthly salary in Indian Rupees? *
Have you heard of a Praana Charitable Clinic before today? *
How did you hear about this Praana Charitable Clinic? *
Place of residence: *
How many kilometers did you travel to arrive at this Praana Charitable Clinic? *
Mode of transportation to this Praana Charitable Clinic. (Select all that apply) *
Required
Please select all services you received during your visit today at this Praana Charitable Clinic. *
Required
Please specify the amount of currency you paid for your services today at this Praana Charitable Clinic. *
Have you seen an allergy/asthma specialist before today? *
Has anything prevented you from seeing an allergy specialist prior to today? Select all that apply. *
Required
How pleased are you to visit with a Praana doctor today? *
In what areas can we improve our medical services? *
Will you spread the message of Praana Charitable Clinics to your social circles? *
Thank you for receiving your medical services today at this Praana Charitable Asthma Allergy Clinic.  Please add your suggestions or comments.
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