Patient Experience Form (Adult)

"*" indicates required fields

Thank you for agreeing to complete this survey. Your Anaesthetist 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 Patient Experience Survey is to understand your experiences to help your Anaesthetist improve their services to patients, with a focus on professional development.

Your feedback is confidential and most questions are optional.

The administrator of this survey is Anaesthetic Group. We will summarise your Anaesthetist's results from individual patient forms onto a summary sheet. Please be assured that you will not be identified, as your Anaesthetist 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 link ONLY from your Anaesthetist's page
(or visit anaestheticgroup.com.au to search for your Anaesthetist) 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

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

Date of Operation*

DD slash MM slash YYYY

Patient's gender

Please tell us your gender: eg. Female, Male, or the gender identity you most identify with

Patient's age*

If the patient was under 18, please complete the Child Form Here

Before your Anaesthetic

Did you have pain before your procedure?

Yes

Was your Anaesthetist involved in managing your pain before your procedure?

Yes

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

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

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

With regards to your Anaesthetist listening to you, are there any comments you would like to make?

Did you feel rushed?

Yes

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

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

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

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

With regards to your Anaesthetist's fees, are there any comments you would like to make?

After your Anaesthetic

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

Yes

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 in pain after the operation?

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

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?

Hidden

Did you have a sore throat after your procedure?

Yes - mild discomfort

Yes - severe sore throat

Hidden

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

Hidden

Admin (ignore)

This field is for validation purposes and should be left unchanged.

Patient Experience Form (Adult)

Before your Anaesthetic

After your Anaesthetic

Thinking about your overall anaesthetic experience...

PATIENTS

SURGEONS

ANAESTHETISTS