Patient Satisfaction Survey General QuestionsFirst Name (optional)Last Name (optional)Treatment Date Date Format: MM slash DD slash YYYY What treatment did you have?Kidney StoneGreenLight PVP (Prostate)Where did you have your treatment?Park Ridge, ILLaGrange, ILAlbuquerque, NMPlease answer the following questions on a scale of 1 to 5, 5 being the highest level of satisfaction. StaffUnderstanding of what you said12345Taking enough time with you12345Telling you what you need to know12345Anesthesia Tech (the person that helped you change your clothes and assisted the doctor)Understanding of what you said12345Taking enough time with you12345Telling you what you need to know12345Technologist (the person that took the x-ray and helped with your treatment)Understanding of what you said12345Taking enough time with you12345Telling you what you need to know12345Nurse (helped you in the Recovery Room after treatment and spoke to you on the phone)Understanding of what you said12345Taking enough time with you12345Telling you what you need to know12345Billing OfficeDid you receive the help you needed with your medical insurance and billing questions?12345Pain ManagementDuring your stay, how often did our staff do everything they could to help you with your pain?12345Did the nursing staff explain how to take care of your pain at home?12345Rate your pain 24 hours following treatment on a scale from 0 to 10:12345678910After the TreatmentDid you have a temperature over 101 degrees after your treatment?YesNoDid you find the information handouts helpful?12345Was the treatment explained to you in an easy to understand language?12345On a scale of 1 to 5, how well did our staff instruct you?12345Privacy and SecurityDid you feel that your personal safety and the safety of the clinical environment were protected?12345Do you feel that the privacy and security of your personal health information was protected?12345Would you come here again if necessary?YesNoPlease rate the overall care you received at United Shockwave Therapies:1 = poor, 2 = unsatisfactory, 3 = satisfactory, 4 = good, 5 = excellent12345Is there any area you think we could improve?Is there anything with which you were particularly pleased?Do you have any additional comments?
