Post-Surgery Patient Feedback Questionnaire
Please help us improve our services by sharing your experience after your recent surgery. Your feedback is confidential and valuable.
Patient Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Surgery
*
Please Select
Orthopedic Surgery
Cardiac Surgery
General Surgery
Plastic Surgery
Neurosurgery
Other
Please rate the following aspects of your post-surgery experience:
*
Rows
Very Poor
Poor
Fair
Good
Excellent
Pain management
1
2
3
4
5
Communication with doctors
6
7
8
9
10
Communication with nurses
11
12
13
14
15
Cleanliness of the facility
16
17
18
19
20
Comfort of your room
21
22
23
24
25
How well did you understand your discharge instructions?
*
Very well
Somewhat well
Not well
Overall, how satisfied are you with the care you received?
*
1
2
3
4
5
Did you experience any complications after your surgery?
*
Yes
No
Would you recommend our hospital to others needing similar care?
*
Definitely
Probably
Not Sure
Probably Not
Definitely Not
Please share any additional comments or suggestions to help us improve our services.
Submit Feedback
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