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The Fetal Heart Program Satisfaction Survey
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1.
What number visit was this to The Fetal Heart Clinic?
(Required.)
1st
2nd
3rd
Other (please specify)
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2.
How long did you wait from your appointment time to be seen?
(Required.)
< 15 mintues
15-30 minutes
30-45 minutes
>45 minutes
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3.
What is your baby's diagnosis?
(Required.)
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4.
Was the information you received presented in a way that you could understand your baby's diagnosis and management plan?
(Required.)
Yes
No
Other (please specify)
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5.
Did you receive adequate education material for home use?
(Required.)
Yes
No
Other (please specify)
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6.
Do you feel that you received answers to all of the questions you had at today's visit?
(Required.)
Yes
No
Other (please specify)
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7.
Was The Fetal Heart Team responsive to your emotional needs today?
(Required.)
Yes
No
Other (please specify)
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8.
What is your level of confidence in The Fetal Heart Team's ability to manage you and your baby's care prenatally?
(Required.)
1 (No Confidence)
2
3
4
5 (Full Confidence)
9.
What did we do well at today's visit?
10.
What could we do to improve today's visit?