* = Required Information

Patient Name* Date

We were privileged to participate in your care. We are interested rendering quality care to our clients and would appreciate your answering the following questions. Your evaluation will allow us to be more responsive to future client/family needs.

1. What services(s) did you receive from the Agency?
Nursing Home Health Aide
Speech Therapy Occupational Therapy
Physical Therapy Medical Social Worker
2. Were you satisfied with the care you received? YesNo
IF NOT, WHY?
3. Did you participate in your plan of care? YesNo
4. Did you receive and understand your "Bill of Rights" including the toll free "Hotline" number that you could call if any problems were not resolved by the Agency? YesNo
5. Did the staff visit as frequently as they stated they would when they started your services? YesNo
6. Were you comfortable asking staff about your health? YesNo
7. Did the staff person visit at a mutually agreeable time? YesNo
8. If you had therapy, were exercise instructions given to you in a clear, written manner that you could easily understand? YesNo
9. Did you feel that you were discharged appropriately? YesNo
10. Would you use the services of the Agency in the future? YesNo
IF NOT, WHY?
Suggestions for improvement:

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