Patient & Family Satisfaction Survey

Thank you for allowing us to provide care for you or your family member. We're interested in your ideas and opinions about our care and services. Please take a moment to answer the following questions. Additional comments are welcomed and can be recorded at the end of the survey. If you need assistance in completing this survey, please feel free to ask your nurse or contact our office. This survey is best completed on computer or tablet.

- Step 1 of 5

Your Overall Experience *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Overall, how would you rate your experience with us?

How can we improve? *

We're sorry you did not have a good experience. Please let us know how we can do better.

How satisfied are you with with care provided by:

	Very Satisfied	Satisfied	Unsatisfied	Very Unsatisfied	N/A
Nurse(s)	Very SatisfiedNurse(s) Very Satisfied	SatisfiedNurse(s) Satisfied	UnsatisfiedNurse(s) Unsatisfied	Very UnsatisfiedNurse(s) Very Unsatisfied	N/ANurse(s) N/A
Physical Therapist	Very SatisfiedPhysical Therapist Very Satisfied	SatisfiedPhysical Therapist Satisfied	UnsatisfiedPhysical Therapist Unsatisfied	Very UnsatisfiedPhysical Therapist Very Unsatisfied	N/APhysical Therapist N/A
Occupational Therapist	Very SatisfiedOccupational Therapist Very Satisfied	SatisfiedOccupational Therapist Satisfied	UnsatisfiedOccupational Therapist Unsatisfied	Very UnsatisfiedOccupational Therapist Very Unsatisfied	N/AOccupational Therapist N/A
Speech/Language Therapist	Very SatisfiedSpeech/Language Therapist Very Satisfied	SatisfiedSpeech/Language Therapist Satisfied	UnsatisfiedSpeech/Language Therapist Unsatisfied	Very UnsatisfiedSpeech/Language Therapist Very Unsatisfied	N/ASpeech/Language Therapist N/A
Medical Social Worker	Very SatisfiedMedical Social Worker Very Satisfied	SatisfiedMedical Social Worker Satisfied	UnsatisfiedMedical Social Worker Unsatisfied	Very UnsatisfiedMedical Social Worker Very Unsatisfied	N/AMedical Social Worker N/A
Home Health Aide(s)	Very SatisfiedHome Health Aide(s) Very Satisfied	SatisfiedHome Health Aide(s) Satisfied	UnsatisfiedHome Health Aide(s) Unsatisfied	Very UnsatisfiedHome Health Aide(s) Very Unsatisfied	N/AHome Health Aide(s) N/A

How strongly do you agree or disagree? Please select your opinion:

	Strongly Agree	Agree	Disagree	Strongly Disagree	N/A
We explained the care/services to be provided and the expected outcomes of care.	Strongly AgreeWe explained the care/services to be provided and the expected outcomes of care. Strongly Agree	AgreeWe explained the care/services to be provided and the expected outcomes of care. Agree	DisagreeWe explained the care/services to be provided and the expected outcomes of care. Disagree	Strongly DisagreeWe explained the care/services to be provided and the expected outcomes of care. Strongly Disagree	N/AWe explained the care/services to be provided and the expected outcomes of care. N/A
I was involved in the decision-making process about my plan of care from admission to discharge.	Strongly AgreeI was involved in the decision-making process about my plan of care from admission to discharge. Strongly Agree	AgreeI was involved in the decision-making process about my plan of care from admission to discharge. Agree	DisagreeI was involved in the decision-making process about my plan of care from admission to discharge. Disagree	Strongly DisagreeI was involved in the decision-making process about my plan of care from admission to discharge. Strongly Disagree	N/AI was involved in the decision-making process about my plan of care from admission to discharge. N/A
Staff treated me, my family, my home and belongings with respect.	Strongly AgreeStaff treated me, my family, my home and belongings with respect. Strongly Agree	AgreeStaff treated me, my family, my home and belongings with respect. Agree	DisagreeStaff treated me, my family, my home and belongings with respect. Disagree	Strongly DisagreeStaff treated me, my family, my home and belongings with respect. Strongly Disagree	N/AStaff treated me, my family, my home and belongings with respect. N/A
Staff explained my conditions, rights and responsibilities, and other procedures to the care I received.	Strongly AgreeStaff explained my conditions, rights and responsibilities, and other procedures to the care I received. Strongly Agree	AgreeStaff explained my conditions, rights and responsibilities, and other procedures to the care I received. Agree	DisagreeStaff explained my conditions, rights and responsibilities, and other procedures to the care I received. Disagree	Strongly DisagreeStaff explained my conditions, rights and responsibilities, and other procedures to the care I received. Strongly Disagree	N/AStaff explained my conditions, rights and responsibilities, and other procedures to the care I received. N/A
Staff assisted me with managing my pain and discomfort.	Strongly AgreeStaff assisted me with managing my pain and discomfort. Strongly Agree	AgreeStaff assisted me with managing my pain and discomfort. Agree	DisagreeStaff assisted me with managing my pain and discomfort. Disagree	Strongly DisagreeStaff assisted me with managing my pain and discomfort. Strongly Disagree	N/AStaff assisted me with managing my pain and discomfort. N/A
The staff generally arrived as scheduled.	Strongly AgreeThe staff generally arrived as scheduled. Strongly Agree	AgreeThe staff generally arrived as scheduled. Agree	DisagreeThe staff generally arrived as scheduled. Disagree	Strongly DisagreeThe staff generally arrived as scheduled. Strongly Disagree	N/AThe staff generally arrived as scheduled. N/A
When I called the office, the representative was courteous and available, and directed my call correctly.	Strongly AgreeWhen I called the office, the representative was courteous and available, and directed my call correctly. Strongly Agree	AgreeWhen I called the office, the representative was courteous and available, and directed my call correctly. Agree	DisagreeWhen I called the office, the representative was courteous and available, and directed my call correctly. Disagree	Strongly DisagreeWhen I called the office, the representative was courteous and available, and directed my call correctly. Strongly Disagree	N/AWhen I called the office, the representative was courteous and available, and directed my call correctly. N/A

How likely are you to

	Very Likely	Likely	Unlikely	Very Unlikely	N/A
Use us again	Very LikelyUse us again Very Likely	LikelyUse us again Likely	UnlikelyUse us again Unlikely	Very UnlikelyUse us again Very Unlikely	N/AUse us again N/A
Recommend us to friends and relatives	Very LikelyRecommend us to friends and relatives Very Likely	LikelyRecommend us to friends and relatives Likely	UnlikelyRecommend us to friends and relatives Unlikely	Very UnlikelyRecommend us to friends and relatives Very Unlikely	N/ARecommend us to friends and relatives N/A

Would you like to provide any additional comments or suggestions?

What impressed you the most about our care/services?

Thank you for your valuable feedback. This confidential information will be used only in efforts to improve our care and services.

Name

First

Last

Phone

Message