Patient Experience Survey

Patient Experience Survey

Please fill out the post anaesthetic survey below and click [submit] to send back to us. Fields marked with '*' must be filled in. If you wish to remain anonymous, please do not fill in your name or contact details or optional choices.
Name (Optional)

First NameLast Name
Phone Number (Optional)
Email (Optional)
Date of Surgery*

DayMonthYear
Date
Hospital
Name of Anaesthetist*
Your Age

18-2425-3435-4445-5455-6465-7475 or older
Your Gender

MaleFemalePrefer not to say
Questions
1. Were you happy with the service provided by the anaesthetic office?

YesNo
2. Were you happy with the information provided prior to your anaesthetic?

YesNo
3. Did you feel like you had time to ask your anaesthetist questions before your surgery?

YesNo
If yes, how well were those questions answered?

PoorlyBelow AverageAverageAbove AverageExcellent
4. Did you understand the information about your anaesthetic that was given to you before your surgery?

YesNo
If yes, how useful did you find the information?

Not usefulSomewhat usefulUsefulVery UsefulEssential
5. Did you feel like your anaesthetist listened to you?

YesNo
6. Did you feel rushed?

YesNo
7. Did you feel scared or anxious before your surgery?

YesNo
If yes, how well did your anaesthetist manage your fear and anxiety?

PoorlyBelow AverageAverageAbove AverageExcellent
8. Did your anaesthetist explain to you how you might feel after the surgery?

YesNo
9. Did you feel nauseated and/or vomit after the surgery?

NoneMildModerateSevere
If yes, how well was it treated?

PoorlyBelow AverageAverageAbove AverageExcellent
10. Did you have pain before surgery?

YesNo
11. Were you in pain after the operation?

NoneMildModerateSevere
If yes, how well was your pain managed?

PoorlyBelow AverageAverageAbove AverageExcellent
12. Were you cold or shivering after the surgery?

YesNo
If yes, how well was it managed?

PoorlyBelow AverageAverageAbove AverageExcellent
13. Did you have difficulty in urinating after surgery?

NoneSometimesMost of the TimeAll the Time
14. Did you have difficulty in sleeping after surgery?

NoneSometimesMost of the TimeAll the Time
15. Overall, did you feel you had a positive or negative experience?

PositiveNegative
16. Are there any comments you would like to make in relation to any of the previous questions.
17. Do you have any suggestions about how your care could have been improved?
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Patient Experience Survey

Questions