Post-Op Feedback Form (Child) "*" indicates required fields This form is to be completed by the Parent (carer or guardian) that was with your child during the anaesthetic. For questions with ratings, 1 is poor and 5 is excellentThis survey is regarding: HiddenChild's name (optional) Gender of child* Female Male Other Prefer not to say Child's age*Please select0 - 2 yrs3 - 4 yrs5 - 6 yrs7 - 10 yrs11 - 12 yrs13 - 18 yrsDate of Operation* DD slash MM slash YYYY Before the AnaestheticDid the Anaesthetist take effort to ensure there was privacy when talking to you and the Child?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentWas your Child anxious before the procedure? Yes No Did the Anaesthetist make an effort to minimise your Child's anxiety or fear of the procedure?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentCommunication between the Anaesthetist and the Parent: Did the Anaesthetist listen carefully to you as the Parent?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentDid the Anaesthetist explain things to you in a way that was easy to understand?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentDid the Anaesthetist treat you with courtesy and respect?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentCommunication between the Anaesthetist and the Child:Did the Anaesthetist listen carefully to the Child?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentDid the Anaesthetist talk and act in a way that was appropriate for your Child's age?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentDid the Anaesthetist explain things to your Child in a way that was easy for your Child to understand?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentDid the Anaesthetist encourage your Child to ask questions?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentDid the Anaesthetist involve your Child in discussion of their care?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentDid 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 the AnaestheticDid the Anaesthetist provide information about what to expect and how to care for your Child after the procedure?Please select1 - No - Poor2 - No - Below Average3 - Average4 - Yes - Above Average5 - Yes - ExcellentWas your Child uncomfortable with pain after the procedure? No - no pain Yes - mild pain Yes - severe pain How effective was the pain management?Please select1 - Poor2 - Below Average3 - Average4 - Above Average5 - ExcellentDid your Child have any nausea or vomiting after the procedure? Yes - nausea Yes - vomiting No vomiting or nausea How was the management of your Child's nausea or vomiting?Please select1 - Poor2 - Below Average3 - Average4 - Above Average5 - ExcellentWere there any problems with the anaesthetic? No - there were no problems that I know of Yes - there were problems Did the Anaesthetist personally advise you of the problems? Yes - the Anaesthetist advised me (or us) personally No - someone else advised me (or us) of the problems Thinking about your overall anaesthetic experience...Comments - Would you like to make any comments about the experience?Suggestions - Do you have any suggestions on how the care of your Child by the Anaesthetist could have been improved?If your Child were to have another anaesthetic, would you be happy to have the same Anaesthetist? Yes No EmailThis field is for validation purposes and should be left unchanged.
