DISCHARGE QUESTIONNAIRE
Your age:
Sex:
Department of residency:
Hospital Department:
Your answer
Entry date:
MM
/
DD
/
YYYY
Exit date:
MM
/
DD
/
YYYY
Did you give written consent for the treatment you received:
PLEASE GIVE US YOUR FEEDBACK
* Reception
* Identification of the different people working in the departmenttravaillant dans le service
* Respect of privacy
* Information given by the medical team
* Information given by the doctors/surgeons
* Information given by the anaesthesiologist
* Information concerning your treatment
* Doctors' listening skills
* Medical team's listening skills
* Administrative personnel's listening skills
* Clearness of the doctors' responses to your questions
* Courtesy and helpfulness of the staff
* Staff availability
* Help with normal everyday activities (meals, washing up…)
* Staff response time to requests
* Waiting time for additional tests/examinations (ex: x-rays….)
* Overall handling of your health
* In case of pain, the treatment offered was
* Respect of your rest
* Dietary suggestions
* Respect of menu choice
* Variety of dishes/meals offered
* Organisation of your discharge (documents, transportation, prescriptions…)
* Explications delivered for prescribed medications upon discharge
* Information on possible activities after discharge
* Information on home-care after discharge
OVERALL : WHAT OVERALL SCORE WOULD YOU ATTRIBUTE TO THE HOSPITAL
UNSATISFACTORY
VERY SATISFACTORY
COMMENTS AND SUGGESTIONS:
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms