Patient Feedback Survey

Your Name (optional):

Physician discussed condition and reason for hospitalization:

Yes

Additional comments:

Patient feels their pain was managed appropriately:

Yes

Additional comments:

2. Patient Privacy and Safety:

Patient safety instructions discussed with patient:

Yes

Additional comments:

Patient understands reason for surgery:

Yes

Additional comments:

Risk and benefits of surgery explained:

Yes

Additional comments:

3. Overall Assessment:

	Poor	Fair	Average	Good	Excellent
Overall satisfaction of hospital stay
Overall cleanliness of the hospital
Satisfaction with hospital room

Additional comments:

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

What code is in the image?: *

Enter the characters (without spaces) shown in the image.

Useful Links