Date of Procedure
MM
DD
YYYY
1. Before your procedure, did your doctor or anyone from the facility give you all the information you needed about your procedure?
Yes, definitely
Yes, somewhat
No
2. Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?
Yes, definitely
Yes, somewhat
No
3. Did the check-in process run smoothly?
Yes, definitely
Yes, somewhat
No
4. Was the facility clean?
Yes, definitely
Yes, somewhat
No
5. Were the clerks and receptionists at the facility as helpful as you thought they should be?
Yes, definitely
Yes, somewhat
No
6. Did the clerks and receptionists at the facility treat you with courtesy and respect?
Yes, definitely
Yes, somewhat
No
7. Did the doctors and nurses treat you with courtesy and respect?
Yes, definitely
Yes, somewhat
No
8. Did the doctors and nurses make sure you were as comfortable as possible?
Yes, definitely
Yes, somewhat
No
9. Did the doctors and nurses explain your procedure in a way that was easy to understand?
Yes, definitely
Yes, somewhat
No
10. Anesthesia is something that would make you feel sleepy or go to sleep during your procedure. Were you given anesthesia? If No, skip to question #13
Yes
No
11. Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand?
Yes, definitely
Yes, somewhat
No
12. 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, definitely
Yes, somewhat
No
13. Discharge instructions 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?
Yes
No
14. Did your doctor or anyone from the facility prepare you for what to expect during your recovery?
Yes, definitely
Yes, somewhat
No
15. 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, definitely
Yes, somewhat
No
16. At any time after leaving the facility, did you have pain as a result of your procedure?
Yes
No
17. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting?
Yes, definitely
Yes, somewhat
No
18. At any time after leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia?
Yes
No
19. 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, definitely
Yes, somewhat
No
20. At any time after leaving the facility, did you have bleeding as a result of your procedure?
Yes
No
21. 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, definitely
Yes, somewhat
No
22. At any time after leaving the facility, did you have any signs of infection?
Yes
No
23. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?
24. Would you recommend this facility to your friends and family?
Definitely no
Probably no
Probably yes
Definitely yes
25. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair Poor
26. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair Poor
27. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 79
80 to 84
85 or older
28. Are you male or female?
Male
Female
29. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
30. Are you of Hispanic, Latino, or Spanish origin? If no, skip to question 3
Yes, Hispanic, Latino, or Spanish
No, not Hispanic, Latino, or Spanish
31. Which group best describes you?
Mexican, Mexican American, Chicano
Puerto Rican
Cuban
Another Hispanic, Latino, or Spanish origin
32. What is your race?
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
33. How well do you speak English?
Very well
Well
Not well
Not at all
34. Do you speak a language other than English at home? If no, skip to question 36
Yes
No
35. What is that language?
Spanish
Other Language
36. Did someone help you complete this survey? If no skip to end.
Yes
N
37. Did someone help you complete this survey?
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way:
Comments
Additional comments here
No one helped me complete this survey
