Emergency Department Patient Experience
ED Visit Survey
Are you male of female?
Are you male of female?
Male
Female
What is your age?
What is your age?
Is your child male or female?
Is your child male or female?
Male
Female
What is the age of your child?
What is the age of your child?
*
Why did you visit the emergency room?
Why did you visit the emergency room?
Injury or accident
Illness
Mental Health
Other (please specify)
*
How long did you wait in the waiting area to be seen by a staff member?
How long did you wait in the waiting area to be seen by a staff member?
*
How long did you wait in the exam room to be seen by a physician or nurse practitioner?
How long did you wait in the exam room to be seen by a physician or nurse practitioner?
*
How satisfied were you with the ease of registration?
How satisfied were you with the ease of registration?
Very satisfied
Somewhat satisfied
Undecided
Somewhat dissatisfied
Very dissatisfied
*
How satisfied were you with the friendliness of the registration staff?
How satisfied were you with the friendliness of the registration staff?
Very satisfied
Somewhat satisfied
Undecided
Somewhat dissatisfied
Very dissatisfied
1 / 3
33%
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