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Thank you for taking the time to complete this questionnaire. Your information will be very helpful as we seek to provide only the highest quality care to the people in this community. |
Please answer all questions with a "yes" or "no" answer. Any comments can be written in the space provided below. |
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Patient Name |
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Date of Service Format: mm/dd/year |
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Date Survey Completed Format: mm/dd/year |
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Question #1: Was the parking adequate? |
yes no
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Question #2: Were signs adequate and effective? |
yes no
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Question #3: Was the facility neat and clean? |
yes no
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Question #4: Did you feel at ease during and after the registration |
yes no
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Question #5: Were you satisfied with the length of time to start treatment? |
yes no
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Question #6: Were the personnel courteous and respectful? |
yes no
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Question #7: Were the doctors courteous and respectful? |
yes no
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Question #8: Were your room and bathroom kept clean? |
yes no
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Question #9: Were you satisfied with your meals? (within the limits of your diet) |
yes no
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Question #10: During your hospital stay, did the doctors, nurses or other hospital staff explain and involve you in decisions about your treatment as much as you wanted? |
yes no
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Question #11: During your hospital stay, did you experience pain? (If not, skip to question #13.) |
yes no
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Question #12: Were you satisfied with how well your pain was controlled? |
yes no
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Question #13: Did you understand your discharge instructions? |
yes no
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Question #14: Did you feel like your privacy was protected? |
yes no
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Question #15: Did you feel that your safety was assured at all times? |
yes no
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Question #16: Would you recommend this hospital to your friends and family? |
yes no
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Question #17: Is there at least one person who stood out in meeting your needs while in the hospital? (If so, please write the employees name in the coment box.) |
yes no
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Comments |
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