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PATIENT SATISFACTION SURVEY
Complete both surveys Survey 1 of 2
*
Indicates required field
Patients Name
*
First
Last
Your Name
*
First
Last
Email
*
Phone Number
*
1. Professional, courteous, timely service provided by the staff
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Excellent
Good
Average
Fair
Poor
If Other please specify:
*
2. My pain is being managed by current medication regime
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Excellent
Good
Average
Fair
Poor
If Other, please specify
*
3. Instruction and / or treatments clearly and thoroughly explained by staff
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Excellent
Good
Average
Fair
Poor
If Other, please specify
*
4. In all my contact with hospice staff, I feel that all my questions were answered appropriately
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Excellent
Good
Average
Fair
Poor
If Other, please specify
*
5. Continuity of staff members providing care
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Excellent
Good
Average
Fair
Poor
If Other, please specify
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6. Services provided helped me/ my family meet all health needs
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Excellent
Good
Average
Fair
Poor
If Other, please specify
*
7. The overall quality of services provided were
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Excellent
Good
Average
Poor
Fair
If Other, please specify
*
Submit
Survey 2 of 2
*
Indicates required field
Patients Name
*
First
Last
Your Name
*
First
Last
Email
*
Phone Number
*
8. I was notified of schedule changes in advance
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Excellent
Good
Average
Fair
Poor
If Other please specify:
*
9. I was treated with a positive and helpful attitude by staff members
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Excellent
Good
Average
Fair
Poor
If Other, please specify
*
10. I feel that enough time was taken by the field staff in providing care for me
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Excellent
Good
Average
Fair
Poor
If Other, please specify
*
11. Home visits were made on day(s) and time(s) I was informed they would be
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Excellent
Good
Average
Fair
Poor
If Other, please specify
*
12. I was informed of how to contact the hospice after hours
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Excellent
Good
Average
Fair
Poor
If Other, please specify
*
13. Equipment and supplies were delivered on time
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Excellent
Good
Average
Fair
Poor
If Other, please specify
*
14. Medication was delivered on time
*
Excellent
Good
Average
Fair
Poor
If Other, please specify
*
Submit
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