Patient Survey Template

• Department

• Conducted on

  Date

• Prepared by

• Location
  Address

Care from Nurses

• During this hospital stay, how often did nurses treat you with courtesy and respect?

  Never

  Sometimes

  Usually

  Always

• During this hospital stay, how often did nurses listen carefully to you?

  Never

  Sometimes

  Usually

  Always

• During this hospital stay, how often did nurses explain things in a way you could understand?

  Never

  Sometimes

  Usually

  Always

• During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

  Never

  Sometimes

  Usually

  Always

Care from Doctors

• During this hospital stay, how often did doctors treat you with courtesy and respect?

  Never

  Sometimes

  Usually

  Always

• During this hospital stay, how often did doctors listen carefully to you?

  Never

  Sometimes

  Usually

  Always

• During this hospital stay, how often did doctors explain things in a way you could understand?

  Never

  Sometimes

  Usually

  Always

Hospital Environment

• During this hospital stay, how often were your room and bathroom kept clean?

  Never

  Sometimes

  Usually

  Always

• During this hospital stay, how often was the area around your room quiet at night?

  Never

  Sometimes

  Usually

  Always

Hospital Experience

• During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?

  Yes

  No

• How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

  Never

  Sometimes

  Usually

  Always

• During this hospital stay, did you have any pain?

  Yes

  No

• During this hospital stay, how often did hospital staff talk with you about how much pain you had?

  Never

  Sometimes

  Usually

  Always

• During this hospital stay, how often did hospital staff talk with you about how to treat your pain?

  Never

  Sometimes

  Usually

  Always

• During this hospital stay, were you given any medicine that you had not taken before?

  Yes

  No

• Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

  Never

  Sometimes

  Usually

  Always

• Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

  Never

  Sometimes

  Usually

  Always

Leaving the Hospital

• Before leaving, do you intend to go directly to your own home, to someone else’s home, or to another health facility?

  Own home

  Someone else’s home

  Another health facility

• During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

  Never

  Sometimes

  Usually

  Always

• During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

  Never

  Sometimes

  Usually

  Always

Overall Rating of the Hospital

• Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

  Select 10 - Best hospital possible 9 8 7 6 5 4 3 2 1 0 - Worst hospital possible

  • 10 - Best hospital possible
  • 9
  • 8
  • 7
  • 6
  • 5
  • 4
  • 3
  • 2
  • 1
  • 0 - Worst hospital possible

• Would you recommend this hospital to your friends and family?

  Definitely Yes

  Probably Yes

  Probably No

  Definitely No

About you

• During this hospital stay, were you admitted to this hospital through the Emergency Room?

  Yes

  No

• In general, how would you rate your overall health?

  Excellent

  Very good

  Good

  Fair

  Poor

• In general, how would you rate your overall mental or emotional health?

  Excellent

  Very good

  Good

  Fair

  Poor

• What is the highest grade or level of school that you have completed?

  Select 8th grade or less Some high school, but did not graduate High school graduate or GED Some college or 2-year degree 4-year college graduate More than 4-year college degree

  • 8th grade or less
  • Some high school, but did not graduate
  • High school graduate or GED
  • Some college or 2-year degree
  • 4-year college graduate
  • More than 4-year college degree

• Are you of Spanish, Hispanic or Latino origin or descent?

  No, not Spanish/Hispanic/Latino

  Yes, Puerto Rican

  Yes, Mexican, Mexican American, Chicano

  Yes, Cuban

  Yes, other Spanish/Hispanic/Latino

• What is your race? Please choose one or more.

  American Indian or Alaska Native

  Native Hawaiian or other Pacific Islander

  Asian

  Black or African American

  White

• What language do you mainly speak at home?

  Select English Spanish Chinese Russian Vietnamese Portuguese Other language

  • English
  • Spanish
  • Chinese
  • Russian
  • Vietnamese
  • Portuguese
  • Other language

• Please identify language

• Overall comments: