Patient Satisfaction Survey Form

1.What services(s) did you receive from the Agency? (circle all that apply)

2.Were you satisfied with the care you received? *

Yes

No

Why

3.Did you participate in your plan of care? *

Yes

No

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 or if you were dissatisfied with the services provided? *

Yes

No

5.Did the staff visit as frequently as they stated they would? *

Yes

No

6.Did you feel comfortable asking staff questions regarding your health? *

Yes

No

7.Did the staff person visit at a mutually agreeable time? *

Yes

No

8.If you had therapy, were exercise instructions given to you in a clear, written manner that you could easily understand? *

Yes

No

N/A

9.Did you feel that you were discharged appropriately? *

Yes

No

10.Would you use the services of the Agency in the future? *

Yes

No

Why

Nursing	Physical Therapy	Occupational Therapy	Speech Therapy
Home Health Aide	Homemaking/Chore Service	Medical Social Worker