Patient Satisfaction Survey

Date Completed:

Surveyor's name:

PATIENT NAME: First: M.I.: Last:

Singleton Twins Trips Quads   Other:

THERAPY: (Check ALL that apply)

  • T-Pump/HUAM
  • HUAM Only
  • GDM
  • PIH
  • Zofran Pump
  • Reglan Pump
  • IV Hydration
  • 17-OH Prog
  • Other:

FLORIDA:

Was your Nurse at Florida Office easy to reach by Phone?
Y N :

Did she return Phone Call Promptly?
Y N :

Did she provide thorough and appropriate information/instructions to you?
Y N :

Were you treated in a Professional Manner?
Y N :

Was she Compassionate & Supportive?
Y N :

Did the Florida Office meet your Expectations?
Y N :

TEXAS:

Was your Nurse Prompt & On-Time?
Y N :

Did she act in a Professional Manner?
Y N :

Did she provide thorough and appropriate information/instructions to you?
Y N :

Was she Compassionate & Supportive?
Y N :

Did the Homecare Nurses meet your Expectations?
Y N :

SERVICE:

Were your expectations of our Service Met?
Y N

Did we Exceed Expectations?
Y N

On a Scale of 1 to 10 (10 being the Best), how satisfied were you with Healthy Connections?

Would you use our Services again if they were Necessary?
Y N :

How Can We Improve Our Services?

Do You Have Anything Else to Add?