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Patient Experience Form (Adult)

This survey is regarding Dr:
Were you the patient?
- Yes
- No
Please complete all of the following questions based on the patient
ie. when the question refers to "you" or "your" please answer on behalf of the patient
Patient's gender*
- Male
- Female
Patient's age*
If the patient was under 18, please complete the Child Form Here
Date of Operation*
Date Format: DD slash MM slash YYYY
Before your Anaesthetic
Did you have pain before your procedure?
- Yes
- No
Was your Anaesthetist involved in managing your pain before your procedure?
- Yes
- No
How well do you think your Anaesthetist managed your pain before your procedure?
(please choose a rating from 1 to 5, where 1 is poor and 5 is excellent)
With regards to any pre-operative pain, are there any comments you would like to make?
Did you feel you had time to ask questions before your procedure?
- Yes
- No
How well were these questions answered by your Anaesthetist?
(please choose a rating from 1 to 5, where 1 is poor and 5 is excellent)
With regards to asking your Anaesthetist questions prior to your procedure, are there any comments you would like to make?
Did you understand the information about your anaesthetic that was given to you before your procedure?
- Yes
- No
How useful did you find the information?
(please choose a rating from 1 to 5, where 1 is poor and 5 is excellent)
With regards to information provided before your procedure, are there any comments you would like to make?
Did you feel like your Anaesthetist listened to you?
- Yes
- No
With regards to your Anaesthetist listening to you, are there any comments you would like to make?
Did you feel rushed?
- Yes
- No
With regards to possibly being rushed, are there any comments you would like to make?
Did you feel scared or anxious before your procedure?
- Yes
- No
How well did your Anaesthetist manage your fear and anxiety?
(please choose a rating from 1 to 5, where 1 is poor and 5 is excellent)
With regards to these feelings and your Anaesthetist's response, are there any comments you would like to make?
Did your Anaesthetist explain to you how you might feel after the procedure?
- Yes
- No
With regards to explanations on how you might feel post-operatively, are there any comments you would like to make?
Did you complete the online health questionnaire prior to your procedure?
- Yes
- No
With regards to the online health questionnaire, are there any comments you would like to make?
Were you informed of your Anaesthetist's fees prior to your admission to hospital?
- Yes
- No
With regards to your Anaesthetist's fees, are there any comments you would like to make?
After your Anaesthetic
Did you have any nausea or vomiting after your procedure?
- Yes
- No
How well was this nausea or vomiting treated?
(please choose a rating from 1 to 5, where 1 is poor and 5 is excellent)
With regards to nausea or vomiting, are there any comments you would like to make?
Were you uncomfortable with pain after your procedure?
- No - no pain
- Yes - mild pain
- Yes - severe pain
How effective was your pain treatment?
(please choose a rating from 1 to 5, where 1 is poor and 5 is excellent)
With regards to post-operative pain, are there any comments you would like to make?
Were you cold or shivering after your procedure?
- Yes
- No
How well was this cold or shivering managed?
(please choose a rating from 1 to 5, where 1 is poor and 5 is excellent)
With regards to feeling cold or shivering, are there any comments you would like to make?
Did you have a sore throat after your procedure?
- No
- Yes - mild discomfort
- Yes - severe sore throat
How long did this sore throat last for?
Thinking about your overall anaesthetic 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 your care could have been improved?
If you were to have another procedure in the future, would you be happy to have the same Anaesthetist?
- Yes
- No

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Patient Experience Form (Adult)

Before your Anaesthetic

After your Anaesthetic

Thinking about your overall anaesthetic experience...

Patients

Surgeons

Anaesthetists