ANAESDOCTORS

Adult Patient

adult patient | ANAESDOCTORS

Thank you for agreeing to be part of this process. The purpose of this survey is to help the anaesthetist improve their service.

Your feedback is confidential. All information is de-identified before being provided to the relevant anaesthetist.

Name

Gender

Age

Date of Surgery DD/MM/YY

Please use the scale of N/A (not applicable), 1 (poor) to 5 (excellent) where appropriate

1. Did you have pain before surgery?

Yes No 1. Please select

2. Was your anaesthetist involved in managing your pain before surgery?

Yes No 2. Please select

If yes, how well do you think we managed your pain?

1 poor 2 3 4 5 excellent 2a. Please select

Are there any comments you would like to make?

2b. Details

3. Did you feel like you had time to ask your anaesthetist questions before your surgery?

Yes No 3. Please select

If yes, how well were those questions answered?

1 poor 2 3 4 5 excellent 3a. Please select

Are there any comments you would like to make?

3b. Details

4. Did you understand the information about your anaesthetic that was given to you before your surgery?

Yes No 4. Please select

If yes, how useful did you find the information?

1 poor 2 3 4 5 excellent 4a. Please select

Are there any comments you would like to make?

4b. Details

5. Did you feel like your anaesthetist listened to you?

Yes No 5. Please select

Are there any comments you would like to make?

5a. Details

6. Did you feel rushed?

Yes No 6. Please select

Are there any comments you would like to make?

6a. Details

7. Did you feel scared or anxious before your surgery?

Yes No 7. Please select

If yes, how well did your anaesthetist manage your fear and anxiety?

1 poor 2 3 4 5 excellent 7a. Please select

Are there any comments you would like to make?

7b. Details

8. Did your anaesthetist explain to you how you might feel after the surgery?

Yes No 8. Please select

Are there any comments you would like to make?

8a. Details

9. Did you feel nauseated and / or vomit immediately after the surgery?

Yes No 9. Please select

If yes, how well was it treated?

1 poor 2 3 4 5 excellent 9a. Please select

Are there any comments you would like to make?

9b. Details

10. Were you in pain after the operation?

Yes No 10. Please select

If yes, how effective was your pain treatment?

1 poor 2 3 4 5 excellent 10a. Please select

Are there any comments you would like to make?

10b. Details

11. Were you cold or shivering after the surgery?

Yes No 11. Please select

If yes, how well was it managed?

1 poor 2 3 4 5 excellent 11a. Please select

Are there any comments you would like to make?

11b. Details

12. If you had a positive or negative experience, please tell us about it.

12. Details

13. Do you have any suggestion about how your care could have been improved?

13. Details

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