Client Exit Interviews Page 3
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1
2
3
4CLINIC CONDITIONS
N
Question
Answer
Pass Std
o
Did different areas in the health clinic seem uncomfortable to you, such as
Yes
No
21
hallways, consulting rooms, bathrooms?
Did any areas in the health clinic seem dirty to you?
Yes
No
22
24
FILL OUT LATER: Did the client find the areas in the health clinic
Yes
No
V.2
23
uncomfortable or dirty? (BASED ON QUESTIONS 21 AND 22)
CONTENTS OF THE CONSULTATION OR COUNSELING SESSION
N
Question
Answer
Pass Std
o
In your visit today, did the provider talk to you about:
How to prevent STIs?
Yes
No
24
How to prevent HIV infection?
Yes
No
25
How to prevent cervical or uterine cancer?
Yes
No
26
How to prevent breast cancer?
Yes
No
27
How to prevent an unwanted pregnancy?
Yes
No
28
30
FILL OUT LATER: Did the provider talk to the client about at least two of
Yes
No
II.4
29
these sexual and reproductive health topics? (BASED ON QUESTIONS 24 –
28)
Did the provider ask whether you are satisfied or dissatisfied with your sexual
Yes
No
30
life?
Did the provider ask whether you have been abused or suffer violence in
Yes
No
31
sexual relations?
Did the provider ask whether your partner participates in preventing unwanted
Yes
No
32
pregnancies?
Did the provider ask whether you can negotiate the use of condoms with your
Yes
No
33
partner?
35
FILL OUT LATER: Did the provider talk to the client about at least two of
Yes
No
II.5
34
these issues? (BASED ON QUESTIONS 30 TO 33)
3
Quality
and
Gender
Accreditation
Reference
Guides
Appendix
IV.1
Clinic
Client
Exit
Interviews
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