Feedback Form
Name (Optional)
Date
Procedure
Pre Admission
Were the reception staff friendly and courteous?
Yes
No
How long did you have to wait before the procedure?
Less than 1/2 hr
Less than an hour
More than an hour
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?
Yes
No
Was the immediate outcome of the procedure and the followup explained by the surgeon?
Yes
No
Please comment on the medical aspects of the visit
Nursing Care
Were the nursing staff attentive
Yes
No
Was pain relief/control required?
Yes
No
If so, was it prompt?
Yes
No
And if so, was it adequate?
Yes
No
Did you feel ill (nauseous) and given something to help it?
Yes
No
If so, was it prompt?
Yes
No
And if so, was it adequate?
Yes
No
General Comfort
Was the temperature of the rooms satisfactory?
Yes
No
Were the furnishings comfortable?
Yes
No
Do you have any comments on the nursing care?
Do you have any suggestions that would help us improve our service to you?
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