Patient Survey Please take a moment to evaluate the care you received at Our Surgery Center. Your honest responses are very important to usbecause you can help us identify any problems that need to be resolved and improve our services. Please enable JavaScript in your browser to complete this form.1. Before your procedure, did your doctor or anyone from the facility give you all the information you needed about your procedure? *Yes, definitelyYes, somewhatNo2. Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure? *Yes, definitelyYes, somewhatNo3. Did the check-in process run smoothly? *Yes, definitelyYes, somewhatNo4. Was the facility clean? *Yes, definitelyYes, somewhatNo5. Were the clerks and receptionists at the facility as helpful as you thought they should be? *Yes, definitelyYes, somewhatNo6. Did the clerks and receptionists at the facility treat you with courtesy and respect? *Yes, definitelyYes, somewhatNo7. Did the doctors and nurses treat you with courtesy and respect? *Yes, definitelyYes, somewhatNo8. Did the doctors and nurses make sure you were as comfortable as possible? *Yes, definitelyYes, somewhatNo9. Did the doctors and nurses explain your procedure in a way that was easy to understand? *Yes, definitelyYes, somewhatNo10. Anesthesia is something that would make you feel sleepy or go to sleep during your procedure. Were you given anesthesia? *YesNoIf no, go to question 1311. Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand? *Yes, definitelyYes, somewhatNo12. Did your doctor or anyone from the facility explain the possible side effects of the anesthesia in a way that was easy to understand? *Yes, definitelyYes, somewhatNo13. Discharge insh·uctions include things like symptoms you should watch for after your procedure, instructions about medicines, and home care. Before you left the facility, did you get written discharge instructions? *YesNo14. Did your doctor or anyone from the facility prepare you for what to expect during your recovery? *Yes, definitelyYes, somewhatNo15. Some ways to control pain include prescription medicine, over-the-counter pain relievers or ice packs. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure? *Yes, definitelyYes, somewhatNo16. At any time after leaving the facility, did you have pain as a result of your procedure? YesNo17. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you bad nausea or vomiting? Yes, definitelyYes, somewhatNo18. At any time after leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia? YesNo19. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure? Yes, definitelyYes, somewhatNo20. At any time after leaving the facility, did you have bleeding as a result of your procedure?YesNo21. Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection? Yes, definitelyYes, somewhatNo22. At any time after leaving the facility, did you have any signs of infection?YesNo23. Using any number from Oto 10, where O is the worst facility possible and IO is the best facility possible, what number would you use to rate this facility? Selected Value: 0 0 Worst facility possible - 10 Best facility possible 24. Would you recommend this facility to your friends and family?Definitely NoProbably NoProbably YesDefinitely YesName *FirstLastOptionalName of PhysicianOptional Date of SurgeryOptionalCommentsOptionalSubmit
