Nurse-Patient Rapport Assessment Form

Nurse-Patient Rapport Assessment Form
Please complete this Nurse-Patient Rapport Assessment Form to help us evaluate the quality of the nurse-patient relationship. Your honest feedback is valuable and will remain confidential.
How would you rate the overall quality of your rapport with your nurse?
My nurse listens carefully to my concerns.

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5
1 is Strongly Disagree, 5 is Strongly Agree
My nurse explains things in a way I can understand.

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5
1 is Strongly Disagree, 5 is Strongly Agree
My nurse treats me with respect.

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5
1 is Strongly Disagree, 5 is Strongly Agree
My nurse shows empathy and understanding.

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5
1 is Strongly Disagree, 5 is Strongly Agree
I feel comfortable discussing my needs with my nurse.

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1 is Strongly Disagree, 5 is Strongly Agree
How often does your nurse check on you during a shift?
Would you recommend your nurse to other patients?
Please indicate your level of agreement with the following statements about your nurse:
Rows Strongly Disagree Disagree Neutral Agree Strongly Agree
My nurse is approachable.
My nurse responds promptly to my needs.
My nurse maintains my privacy.
If you have any additional comments about your experience, please share them below.
Should be Empty:

Select theme:

Rows	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
My nurse is approachable.
My nurse responds promptly to my needs.
My nurse maintains my privacy.