Patient/Family Feedback Survey
1. I am a
*
Patient
Family member
Caregiver
2. How long have you or your family member been in Lake Taupō Hospice care?
*
1 - 3 months
3 - 6 months
+ 6 months
3. Did you or your family member attend any of our Patient Activity Days
*
Yes - Tuesday Group
Yes - Living Well Friday
No activities were attended
4. If you answered Yes. What feedback do you have on these activity days?
5. How satisfied were you with the frequency of contact from Lake Taupō Hospice?
1
2
3
4
5
Leave blank if question is N/A
6. How satisfied were you with the information and advice given by Lake Taupō Hospice?
1
2
3
4
5
Leave blank if question is N/A
7. How satisfied were you with support given by Lake Taupō Hospice?
*
1
2
3
4
5
8. How satisfied were you with respect of the team at Lake Taupō Hospice?
1
2
3
4
5
Leave blank if question is N/A
9. How satisfied were you with the management of symptom or pain management by the team at Lake Taupō Hospice?
1
2
3
4
5
Leave blank if question is N/A
10. How satisfied were you with the equipment delivered by Lake Taupō Hospice?
1
2
3
4
5
Leave blank if question is N/A
11. How satisfied were you with support and advice from the clinical team at Lake Taupō Hospice?
1
2
3
4
5
Leave blank if question is N/A
12. How satisfied were you overall with the services at Lake Taupō Hospice?
1
2
3
4
5
Leave blank if question is N/A
13. Was an Advance Care Plan written while under the care of Lake Taupō Hospice?
Yes
No
Unsure
14. If Yes. Was the Advance Care Plan activated during the care of Lake Taupō Hospice?
Yes
No
Unsure
15. My feedback on the services provided through Lake Taupō Hospice is:
16. My feedback on the team at Lake Taupō Hospice is:
17. My suggestions for improvement of the services at Lake Taupō Hospice are:
Submit
Should be Empty: