Questionnaire

Name (Optional)
Date
Procedure
   
Pre Admission  
   
Were the reception staff friendly and courteous?
How long did you have to wait before the procedure?
If there was a long delay, was a reason given or did you arrive early? Please comment:
   
Medical  
   
Did you receive a satisfactory explanation of the procedure?
Was the immediate outcome of the procedure and the followup explained by the surgeon?
Please comment on the medical aspects of the visit
   
Nursing Care  
   
Were the nursing staff attentive
Was pain relief/control required?
If so, was it prompt?
And if so, was it adequate?
Did you feel ill (nauseous) and given something to help it?
If so, was it prompt?
And if so, was it adequate?
   
General Comfort  
Was the temperature of the rooms satisfactory?
Were the furnishings comfortable?
Do you have any comments on the nursing care?
Do you have any suggestions that would help us improve our service to you?