Feedback Form

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FEEDBACK FORM

We value your feedback!

* Indicates required field

What is your age? *

under 18 (Parent submitting form) 18-25 26-35 36-45 46-59 60-69 70+ Prefer Not to Disclose

If feedback is related to a class, what was your reason for attendance? *

Personal Development Workplace Wellness To Improve/ Better Manage Health Stress Management To Increase Physical Activity Other

If Other, please specify. *

Class Name, Class Topic, or Name of Course Series: *

Enter N/A if Not Applicable

Date of Service or Class? *

Enter exact date or as close as you can remember.

Location of Service or Class? *

Facility location, Address or Name of Individual Host or Host Organization

Who was the Instructor, Coach or Trainer for Class or Service? *

Excellent? (check all that apply) *

Professional & Courteous Well-Prepared Encouraging/ Motivational Attentive Patient Engaging, Smiles Knowledgeable, Q&A Not Applicable, No Opinion

You may make more than 1 selection

Good? (check all that apply) *

Professional & Courteous Well-Prepared Encouraging/ Motivational Attentive Patient Engaging, Smiles Knowledgeable, Q&A Not Applicable, No Opinion

You may make more than 1 selection; check all that apply

Satisfactory? (check all that apply) *

Professional & Courteous Well-Prepared Engaging/ Motivational Attentive Patient Engaging, Smiles Knowledgeable, Q&A Not Applicable, No Opinion

You may make more than 1 selection; check all that apply

Anything Below Expectations? *

Any additional comments you wish to share? *

It is not required for you to provide your contact information unless you want us to follow-up with you regarding any comments provided or you would like the Instructor/ Coach/ Trainer to know specifically who provided the feedback received.

Name *

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Last

Email *

Phone Number *

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"There's nothing more important than our good health -
that's our principal capital asset.

-Arlen Specter

Home
SERVICES
Prevent T2 Diabetes
Healthie Portal Login
Contact
STORE