Patient Feedback Survey
The following information will help us understand the scope of the situation. Kindly provide as much information as you can.
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Contact Information
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First name
Last name
Email
Phone
City
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Province
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Section 1: Perception Around Quality of Care
Please provide as much information as you can.
Are you a patient or a caregiver?
Select an option
Name of Physician
Name of Triage Nurse
How was the reception with the FIRST person encountered? (Such as triage RN?)
Were you in the hospital for pain crisis?
Yes
No
Were you admitted to inpatient ward?
Yes
No
How long was your hospital stay?
How familiar were the health care providers (HCP) with your condition?
Select an option
How respectful were the HCPs of your needs and concerns?
Did you experience any of the following AS A RESULT of you seeking treatment during this interaction? (Select all that apply)
Stigmatization or stereotyping
Anxiety
Helplessness or Isolation
Disrespect
Bullying
Attentiveness
Compassion/empathy
Understanding
Other
Section 2: Hospital Experience in Detail
Please provide details about your hospital experience.
Date of Interaction
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Hospital Name
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Department or Service
Select a department
Name of Physician, Nurse and other clinicians providing optimal or sub-optimal care
Your Experience
Did you receive timely medications while in the hospital?
Yes
No
Did you feel the right investigation/tests were conducted?
Select an option
Did you feel you were attended to in a timely manner?
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Did you feel your concerns were well addressed?
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Did you feel that you had an optimal amount of time?
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Is there anything else you would like us to know about this hospital interaction?
On a scale of 1-10, what would you rate the quality of care you received?
1
2
3
4
5
6
7
8
9
10
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