Patient Experience Form (Pain Medicine) "*" indicates required fields Thank you for agreeing to complete this survey. Your specialist is participating in this voluntary activity as part of the Australian and New Zealand College of Anaesthetists (ANZCA) and Faculty of Pain Medicine (FPM) Continuing Professional Development (CPD) program. The purpose of this survey is to understand your experiences to help your specialist pain medicine physician improve their services to their patients. Your feedback is confidential and most questions are optional. The administrator of this survey is Anaesthetic Group. We will summarise your specialist’s results from individual patient forms onto a summary sheet. Please be assured that you will not be identified, as your specialist will only receive the summarised results and we will also confidentially dispose of your individual form. We appreciate you taking the time to provide this feedback. STOP! PLEASE DO NOT FILL IN THIS FORM. Please click the Patient Experience Survey (PAIN FORM) link ONLY from your Specialist’s page(or visit anaestheticgroup.com.au to search for your Doctor) to complete their form. This form will not go anywhere if you see this message. Please go back!This survey is regarding:* Were you the patient? Yes No If you are completing this form on behalf of the patient, please indicate the reason: I am a parent/caregiver of a child younger than 18 years I am a caregiver of an adult patient who cannot fill this form on their own I am an interpreter Other Please complete all of the following questions based on the patientie. when the question refers to “you” or “your” please answer on behalf of the patientDate of Assessment*Please select the consultation date using the calendar icon or enter it as dd/mm/yyyy eg. 01/12/2024 DD slash MM slash YYYY GenderPlease tell us your gender: eg. Female, Male, or the gender identity you most identify with Age*Please select0 – 18 yrs18 – 24 yrs25 – 34 yrs35 – 44 yrs45 – 54 yrs55 – 64 yrs65 – 74 yrs75 yrs or olderCountry of birth Preferred languages Please rate your pain medicine specialist for the following behaviours:Please choose a rating from 1 to 5, where 1 is poor and 5 is excellent1. Introducing themselves to youPlease select a rating1 – Poor2 – Below Average3 – Average4 – Above Average5 – Excellent2. Being politePlease select a rating1 – Poor2 – Below Average3 – Average4 – Above Average5 – Excellent3. Making you feel at ease(being friendly, not cold or abrupt)Please select a rating1 – Poor2 – Below Average3 – Average4 – Above Average5 – ExcellentWith regards to making you feel at ease, are there any comments you would like to make? 4. Assessing your pain(understanding your condition, asking/knowing details about your situation)Please select a rating1 – Poor2 – Below Average3 – Average4 – Above Average5 – ExcellentWith regards to assessing your pain, are there any comments you would like to make? 5. Explaining the treatment to you(explaining clearly, giving you enough information, not being vague).Please select a rating1 – Poor2 – Below Average3 – Average4 – Above Average5 – ExcellentWith regards to explaining the treatment, are there any comments you would like to make? 6. Involving you in decisions about your treatment(talking with you, encouraging rather than ‘lecturing you’)Please select a rating1 – Poor2 – Below Average3 – Average4 – Above Average5 – ExcellentWith regards to involving you in decisions, are there any comments you would like to make? 7. Answering all your questions(listening and paying attention to what you were saying, not overlooking or dismissing your concerns)Please select a rating1 – Poor2 – Below Average3 – Average4 – Above Average5 – ExcellentWith regards to answering all your questions, are there any comments you would like to make? 8. The pain medicine specialist was approachablePlease select a rating1 – Poor2 – Above Average3 – Average4 – Above Average5 – Excellent9. I had confidence in the pain medicine specialistPlease select a rating1 – Poor2 – Above Average3 – Average4 – Above Average5 – ExcellentThinking about your overall experience…If you had a positive experience, please tell us about it.If you had a negative experience, please tell us about it.Do you have any suggestions about how we could improve our service and care?Would you be happy to see the same pain medicine specialist again? Yes No Are there any other comments you would like to make?HiddenAdmin (ignore) EmailThis field is for validation purposes and should be left unchanged.
