Patient Experience Survey

  • Date Format: MM slash DD slash YYYY
  • Registration

  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Nursing

  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Surgeon

  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Anesthesia/Anesthesiologist

  • Strongly disagreeDisagreeNeutralAgreeStrongly agree
  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Facility

  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Other

  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent
  • Overall Assessment

  • Needs improvementBelow averageFairVery goodExcellent
  • Needs improvementBelow averageFairVery goodExcellent