Recovery Room Feedback Form
Please share your feedback about your experience in the recovery room to help us improve our care.
Full Name
First Name
Last Name
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate your overall experience in the recovery room?
*
1
2
3
4
5
Please rate the following aspects of your recovery room experience:
*
Rows
Excellent
Good
Fair
Poor
Cleanliness of the room
1
2
3
4
Comfort of the bed and environment
5
6
7
8
Noise level
9
10
11
12
Staff professionalism and courtesy
13
14
15
16
Promptness of staff response
17
18
19
20
Pain management
21
22
23
24
Privacy provided
25
26
27
28
Communication about your care
29
30
31
32
Was your pain managed effectively during your stay in the recovery room?
*
Yes
No
Not applicable
How satisfied were you with the communication from the recovery room staff?
*
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
Did you feel your privacy was respected in the recovery room?
*
Yes, always
Most of the time
Sometimes
Never
How long did you wait in the recovery room before being attended by staff?
*
Please Select
Less than 5 minutes
5-10 minutes
10-20 minutes
More than 20 minutes
I don't remember
Would you recommend our facility to others based on your recovery room experience?
*
Yes
No
Not sure
Please provide any additional comments, suggestions, or concerns about your recovery room experience.
Submit Feedback
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