Patient Satisfaction Survey General QuestionsFirst Name (optional) Last Name (optional) Treatment Date MM slash DD slash YYYY What treatment did you have? Kidney Stone GreenLight PVP (Prostate) Where did you have your treatment? Park Ridge, IL LaGrange, IL Albuquerque, NM Please answer the following questions on a scale of 1 to 5, 5 being the highest level of satisfaction. StaffUnderstanding of what you said 1 2 3 4 5 Taking enough time with you 1 2 3 4 5 Telling you what you need to know 1 2 3 4 5 Anesthesia Tech (the person that helped you change your clothes and assisted the doctor)Understanding of what you said 1 2 3 4 5 Taking enough time with you 1 2 3 4 5 Telling you what you need to know 1 2 3 4 5 Technologist (the person that took the x-ray and helped with your treatment)Understanding of what you said 1 2 3 4 5 Taking enough time with you 1 2 3 4 5 Telling you what you need to know 1 2 3 4 5 Nurse (helped you in the Recovery Room after treatment and spoke to you on the phone)Understanding of what you said 1 2 3 4 5 Taking enough time with you 1 2 3 4 5 Telling you what you need to know 1 2 3 4 5 Billing OfficeDid you receive the help you needed with your medical insurance and billing questions? 1 2 3 4 5 Pain ManagementDuring your stay, how often did our staff do everything they could to help you with your pain? 1 2 3 4 5 Did the nursing staff explain how to take care of your pain at home? 1 2 3 4 5 Rate your pain 24 hours following treatment on a scale from 0 to 10: 1 2 3 4 5 6 7 8 9 10 After the TreatmentDid you have a temperature over 101 degrees after your treatment? Yes No Did you find the information handouts helpful? 1 2 3 4 5 Was the treatment explained to you in an easy to understand language? 1 2 3 4 5 On a scale of 1 to 5, how well did our staff instruct you? 1 2 3 4 5 Privacy and SecurityDid you feel that your personal safety and the safety of the clinical environment were protected? 1 2 3 4 5 Do you feel that the privacy and security of your personal health information was protected? 1 2 3 4 5 Would you come here again if necessary? Yes No Please rate the overall care you received at United Shockwave Therapies:1 = poor, 2 = unsatisfactory, 3 = satisfactory, 4 = good, 5 = excellent 1 2 3 4 5 Is there any area you think we could improve?Is there anything with which you were particularly pleased?Do you have any additional comments?
